The Provider Data Coordinator is responsible for performing a broad variety of provider service and operational support such as reviewing, collecting and updating demographics, verification of provider contract set up, account information, group assignment, claim issues, authorization status and various account issues. The Provider Data Coordinator assists to resolve provider questions and issues regarding their association with Seaside Health Plan. This position performs related operational support functions as required; assists or refers providers with any and all questions that arise; and attends to telephone inquiries and transactions for providers.
Essential Functions and Responsibilities of the Job
Understanding of Commercial, Medicare, and Medi-Cal health plan rules and regulations.
Ability to support the Provider Relations Department staff to resolve claims, payment and contracting issues.
Ability to review and processes incoming and outgoing paperwork, including directory updates, provider contract maintenance forms and other related forms.
Maintain provider demographic and contractual data for contracted and non-contracted providers.
Perform quality review and audits to ensure all provider contract information is accurately is accurately reflected in the core system to ensure appropriate provider reimbursement, encounter processing, configuration and overall data integrity.
Ability to give a complete and accurate program description/presentation when asked to do so by answering any questions from providers or their offices and assist them in navigating the website, member or provider portals
Ability to understand and assess the member/provider operational systems at Seaside Health Plan and have the ability to track and assess existing or potential issues with the workflow
Ability to learn and understand the Seaside Health Plan (Commercial and Plan to Plan Agreements) provider network and possess the ability to execute root cause analysis to identify areas of improvement promoting excellent performance
Ability to work with the Pharmacy Benefit Management (PBM) systems to resolve pharmacy issues
Ability to answer phones in less than 30 seconds while providing excellent customer service to the caller; be sure the provider has adequate time to ask all questions and understand all answers by confirming understanding.
Ability to respond professionally, promptly, completely and accurately to questions
Ability to clearly and accurately document telephone conversations/inquiries/complaints (expressions of dissatisfaction) and forward immediately to the appropriate Seaside Health Plan Department (as directed per line of business) in the system notes and as required
Ability to contribute to creating and maintaining a positive work environment
Ability to attend and participate in training and meetings, as assigned
Ability to perform other related duties as assigned
Be at work and be on time.
Follow company policies, procedures and directives
Interact in a positive and constructive manner.
Prioritize and multitask
Essential Job Outcomes
Ensure all provider data is processed timely and accurately
Ensure all provider data is entered accurately and according to the contract
Ensure all provider information is current and forwarded to the appropriate internal and external customers as indicated
Ensure all identified errors are brought to the attention of the appropriate entity and followed through to correction
Work professionally and appropriately with internal and external partners promoting a cohesive work environment
Process NEPs (provider adds) timely and accurately.
Conduct provider relations visits, as directed.
Staff marketing events after-hours and/or weekends, as directed
“Other duties as assigned”
Minimum two year’s experiences in a transaction-based environment such as a call center or similar environment.
Experience in a managed healthcare environment, preferred.
Excellent communications skills including the ability to write and articulate in a clear, concise and persuasive manner to effectively present ideas with ease.
Demonstrated ability to be empathetic and compassionate.
Basic computer skills, including general knowledge of MS Word and Excel applications, type minimum of 45 WPM.
Bi-lingual (Spanish/English). Preferred
High School diploma or GED equivalent, required
Bachelor’s Degree, preferred
Internal Number: SEA000098
About Seaside Health Plan
Let us introduce ourselves. We're MemorialCare, a nonprofit health system that includes four hospitals, two medical groups, imaging centers, surgical centers and much more. As one of the leading health systems in Orange County and Los Angeles County, we're confident that no matter what your needs are, we have the teams, tools and know-how to support you every step of the way.