Provider Services Representative I

Under direction of the Supervisor, this role is responsible for providing accurate and thorough information on the plans benefits, claims, eligibility and policies to our providers and internal customers. In addition he/she is responsible for the resolution of customer inquiries, the facilitation of problem resolution and meeting or exceeding the customers expectation by addressing all of their issues or concerns. He/she is expected to take personal and complete responsibility for every interaction with a customer as a means to build a business relationship, influence customer retention and satisfy corporate customer service goals and objectives.

Duties and Responsibilities:

• Responsible for answering telephone inquiries via the call center and meeting and maintaining all required metrics, including call quality standards.
• Leverage thorough knowledge of company policies, procedures, benefits, claims, and eligibility to respond accurately to provider inquiries
• Very often the first voice of the company for providers, requiring a professional tone and exceptional level of plan, benefits, and claims knowledge
• Establishes and maintains good working relationships with internal and external customers and interacts with other company staff, specifically in Claims, Medical Management, and Provider Network Management to resolve provider inquiries and problems
• Demonstrates basic understanding of company billing guidelines and can effectively interpret and correct misunderstandings related to claims
• Provides accurate documentation regarding inquiries in the Customer Service Call Tracking Applications
• Investigates and refers claims to ensure problem resolution and minimize repeat calls
• Adheres to assigned schedule to ensure proper phone coverage and optimal service levels to providers
• Cultivates strong business relationships with provider community ensuring that network providers receive appropriate and timely responses
• Other duties as assigned
• Corporate Compliance Responsibility - As an essential function, responsible for complying with Neighborhoods Corporate Compliance Program, Standards of Business Conduct, applicable contracts, laws, rules and regulations, policies and procedures as it applies to individual job duties, the department, and the Company. This position must exercise due diligence to prevent, detect and report unlawful and/or unethical conduct by fellow co-workers, professional affiliates and/or agents

Qualifications:

Required:

• High School Degree or equivalent
• One (1) year - Customer Service/Call Center experience
• Typing - strong skillset
• Computer skills - intermediate
• Telephone skills - excellent skillset
• Communication skills (verbal/written) - advanced
• Organizational skills - strong skillset
• Attention to detail
• Ability to handle highly confidential information
• Persistence in locating and securing needed information
• Interpersonal skills - strong
• Work cross-organizationally and with external entities to achieve the goals of the department and organization
• Medical terminology - working knowledge
• Solutions-oriented, positive attitude
• Handle multiple priorities within specific deadlines

Preferred:

• 1+ years - Customer Service/Call Center experience
• 1 2 years - Provider Service/Claims Call Center experience
• Associates Degree or equivalent work experience

Flexible Work Arrangement:

• Candidates must be able and flexible to start work on any given day between 8am and 10am Monday through Friday and to work an 8hour shift, which includes hour uninterrupted unpaid meal break and 10 minute paid break for every 4 hours worked.

Telecommuting Arrangement:

• This position works 100% remote and is assigned to a Permanent Remote Team. Occasional in-person days may be required. The training is in-person and will last about 4-6 weeks.

Training is in-person Mondays-Thursdays and remote on Fridays for about 4-6 weeks starting on May 12, 2025.

Neighborhood Health Plan of Rhode Island is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or veteran status.