Provider Operations Coordinator

Job Description

Job Description

Hybrid- Sunrise, Florida

Position Summary :

Perform day to day duties of assuring that providers (individual, group, ancillary, etc.) are set up accurately in the provider information system for state reporting, claims payment, and directories. Responsible for multiple state deliverables, network reporting and directories as well as claims payment resolution as it relates to provider set up.

Essential Duties and Responsibilities

• Conducts annual after-hours provider survey as mandated by the agency and Florida Healthy Kids Corporation
• Manages and maintains Customer Relations Management (CRM) Pool
• Abides by all compliance requirements for the Agency Health Care Administration, Department of Insurance, and Centers for Medicare and Medicaid Services as these apply to the Provider Operations Department activities
• Assist with out of network negotiations
• Assists in answering the Provider Hotline and provides optimal customer services to all callers
• Reports and maintains history of all telephone encounters and inquiries raised by providers
• Acts as inter-departmental liaison for Claims, Care Coordination, Customer Experience and Utilization Management departments among others
• Assist the Provider Operations Representatives and Provider Operations Contract Negotiators with investigation and resolution of provider issues
• Receive all provider related mail / email / fax, including address changes, claim reconsiderations, general inquiries and determine completion, accuracy, and route accordingly
• Assist in the coordination of completing the credentialing application for providers
• Complete internal directory audits
• Develop and distribute provider notices via fax / email blast
• Educate providers regarding policies and procedures related to referrals and claims submission; web site education, EDI solicitation and problem solving (Provider Hotline)
• Performs other duties as assigned.

This job description in no way states or implies that these are the only duties performed by the employee occupying this position. Employees will be required to perform any other job-related duties assigned by their supervisor or management.

Qualifications :

Skills and Abilities :

Work Schedule :

Community Care Plan is currently following a hybrid work schedule. The company reserves the right to change the work schedules based on the company needs

Physical Demands :

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to sit, use hands, reach with hands and arms, and talk or hear. The employee is frequently required to stand, walk, and sit. The employee is occasionally required to stoop, kneel, crouch or crawl. The employee may occasionally lift and / or move up to 15 pounds.

Work Environment :

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of the job. The environment includes work inside / outside the office, travel to other offices, as well as domestic, travel. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. The noise level in the work environment is usually moderate.

We are an equal opportunity employer who recruits, employs, trains, compensates and promotes regardless of age, color, disability, ethnicity, family or marital status, gender identity or expression, language, national origin, physical and mental ability, political affiliation, race, religion, sexual orientation, socio-economic status, veteran status, and other characteristics that make our employees unique. We are committed to fostering, cultivating, and preserving a culture of diversity, equity, and inclusion.