Provider Network Representative-LifeWise

Job Description: PREMERA. Applying innovation and strategy to create leading-edge health coverage and benefit solutions for our members.

PREMERA's culture promotes individual development, fosters innovation, and rewards success. We are creative, strategic thinkers who use our talents to fulfill our mission of creating peace of mind for our members. First established in 1933, the PREMERA family of health-care companies is headquartered in Washington and serves over 1.5 million members in several Western States. Our unique value proposition is built on a strong local presence and national capabilities.

If you would like to apply your skills and experience to create health-care solutions, consider the following position:

Job Summary:

Act as a liaison between Health Care Delivery Systems and its providers. Provide timely, accurate, courteous, and concise responses to inquiries by telephone, e-mail, fax or written correspondence.

Responsibilities:

1. Provide timely, accurate, courteous and concise responses to inquiries, made by provider offices, HCDS associates and internal departments related to contracts, payment methods, contract types, claims etc. Educate providers and their staff regarding billing, credentialing, contractual requirements, claims and company policies. Present a positive, professional image to providers, peers and all associates. Resolve provider inquiries by investigation/review within department standards/processes.

2. Assure compliance with the National Committee for Quality Assurance (NCQA) and other regulatory agencies/requirements. Assure provider issues as well as inquiries, are accurately documented, initiated and completed. Thoroughly investigate problems/issues by obtaining and/or coordinating information from other internal departments or external organizations, including claims investigation. Identify appropriate RVRBS schedule, fee schedule rules to determine proper claims adjudication.

3. Enforce LifeWise policies and procedures. Inform necessary associates of violations to protocol. Maintain the confidentiality of information relating to our members, providers, contracts and operational protocols.

4. Coordinate with HCDS staff, Care Management, Claims, Credentialing, Quality Improvement and other departments to answer questions, resolve problems and ensure that plan and department requirements are met. Participate in department staff meetings updating staff on provider issues. Assist Customer Service staff with unusual inquiries and unique provider issues. Maintain accurate and complete records on all provider correspondence and special cases.

5. Provide backup for PNEs/PNAs as needed. Perform other duties as assigned.

Minimum Qualifications:

1. Three years experience in a customer service or related environment

2. Knowledge of other internal department operations/functions that assist in resolution of provider inquires. Familiar with current lines of business and products. Knowledge of LifeWise claims paying system and claims paying procedures.

3. Ability to be assertive, professional and compassionate in problem resolution. Demonstrated flexibility, resourcefulness and ability to perform work independently while being an effective team player. Good phone skills. Excellent written and verbal communication skills. Ability to perform effectively in a multiple task environment doing various duties. Public relations and organizational skills. PC skills to include Windows, Word, Excel, and Access. Must be able to travel as needed. Ability to work flexible hours, overtime, including some evenings and weekends.

4. Belief and commitment to the ethical practices in basic business, applying these ethical practices to all LifeWise business interactions.

Additional Qualifications Preferred:

1. One years health insurance industry experience

2. Knowledge of HCDS operations, policies/procedures and processes.


3. Knowledge of contracts, contract types, interpretations and language.

4. Knowledge of CPT coding, ICD-9 codes and medical terminology.

3. Knowledge or experience in health care industry.

Searchable Keywords: Provider Network Representative-LifeWise / gj-mo

Minimum Education Required: High School

Expected Travel Time: None