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Purpose:

The Provider Service representative acts as an advocate for Health Plan customers (providers, vendors, facilities, etc.) by providing guidance, interpretation and education on eligibility levels, benefit design, claim status, and various customer related inquires. Responsible for efficient and courteous resolution to verbal and written inquiries to ensure customer satisfaction while maintaining call servicing and quality standards.

Responsibilities:

+ Actively maintain worklist open cut logs and follow up within the designated time standards.

+ UPMC Health Plan Provider Service Representative must adhere to the following service level standards of excellence: Quality: 98% Monthly Average - Production: 60 calls per day.

+ Maintain employee/insured confidentiality.

+ Provide assistance to other departments during periods of backlogs.

+ Assist with adjustments in accordance with company policies and procedures.

+ Quality customer service will be measured by, but not limited to, the number of complaints from a customer (with a goal of zero) and by the number of second requests for information or response received (with a goal of zero).

+ Interface with customers by telephone or correspondence to answer inquiries and resolve concerns.

+ Quality customer service includes, but is not limited to, responding to customer requests and inquiries in a timely and accurate manner in keeping with Health Plan Policies and Procedures, Department of Public Welfare (DPW) laws and standards, Department of Insurance (DOI) laws and standards, Department of Health (DOH) laws and standards, Department of Health and Human Services (DHHS), Health Care Financing Administration (HCFA), and National Committee for Quality Assurance (NCQA) standards.

+ Quality customer service should be applied to all customers, including all Health Plan members and potential members, all Health Plan providers and potential providers, all Health Plan and Health System employees, all Health Plan and Health System vendors, and all government and other oversight organization staff.

+ Identify any area of concerns that may compromise client satisfaction.

+ Maintain or exceed designated quality standards.

+ Participate in team meetings, provide ideas and suggestions to ensure client satisfaction and promote teamwork.

+ High school graduate or equivalent.

+ 2 years customer service experience or call center experience required. OR1 year health insurance call center and claims adjustments experience required.

+ Keyboard dexterity and accuracy.

+ Excellent knowledge of medical terminology, ICD-9 and CPT-4 coding.

+ Excellent knowledge of HMO, POS and PPO plans, coordination of benefits, subrogation and Medicare.

+ Excellent organizational, interpersonal and communication skills. Competent in MS Office/PC skills.

+ Detail Oriented. **Licensure, Certifications, and Clearances:** **UPMC is an Equal Opportunity Employer/Disability/Veteran**