Provider Service Specialist


Community Health Group is a locally based non-profit health plan that ensures access to high quality, culturally sensitive health care for underserved communities throughout San Diego County. We treat our 300-member, multi-lingual staff like family, encouraging an atmosphere of collaborative teamwork, continuous learning, personal growth, and promotion from within. Recognized as one of the Top Workplaces in San Diego, CHG offers its employees such benefits as tuition reimbursement, a meditation room and yoga classes, a monthly Breakfast With The CEO, and memorable events throughout the year. 

We know that by serving our employees well, they, in turn, will better serve our nearly 300,000+ membership. We have been recognized consistently for the excellence and sensitivity of our customer service by members, physicians, vendors, and a full range of health care providers. We are accredited by the National Committee for Quality Assurance and proud of our continuing company-wide Quality Initiatives.

We are currently recruiting for:

Provider Service Specialist

POSITION SUMMARY

Provides exemplary customer services by serving as liaison between practitioners and providers and Community Health Group for issues related to claims payment and requests for reconsideration or review; using all applicable MAGIC points and complying with regulatory and internal requirements.

COMPLIANCE WITH REGULATIONS:

Works closely with all departments necessary to ensure that the processes, programs and services are accomplished in a timely and efficient manner in accordance with CHG policies and procedures and in compliance with applicable state and federal regulations including CMS and/or Medicare Part D, DHCS and DHMC.

RESPONSIBILITIES

  • Investigates and resolves provider adjustments and requests for adjustment for all product lines by:

    • Evaluating documentation provided by the appellant

    • Identifying if initial claim was paid in accordance with terms and conditions of provider contract or established reimbursement guidelines

    • Adhering to contractual requirements established by regulatory agencies

    • Interpreting policies and procedures from other internal departments (Claims, Health Care Services, and Member Services)

    • Meeting all requirements specified on Provider Dispute Resolution policy and procedure

    • Recommending action (payment, reduction, or denial) based on circumstances identified through case research and investigation

    • Documenting relevant facts related to the case on the appropriate computer module.

  • Provides billing and appeals information to providers for all product lines by answering provider inquiries related to claim status and billing information, providing information regarding CHG’s billing and appeals process and reviewing claim payment methodology based on provider request.

  • Helps achieve telephone performance standards by working closely with other team members to ensure that the telephone abandonment rate does not exceed 2%, and the delay and abandonment time does not exceed 10 seconds.

  • Maintains product and company reputation and contributes to the team effort by conveying professional image and accomplishing related tasks; participating on committees and in meetings; performing other duties as assigned or requested.

     

    Education:

    • High school diploma or equivalent training.  Bachelor’s Degree preferred.

    •  Experience/Skills:

    • Two years experience in customer service and appeals/claims adjudication.

    • Knowledge of database network; claims determination; utilization review and medical terminology.

    • Ability to read, analyze and interpret regulations.

    • Excellent customer service skills.

    • Ability to effectively write and present information.

    • Good judgment and problem solving skills; team player; and ability to work independently.

       

      Physical Requirements:

  • Prolonged periods of sitting and frequent walking.

  • May be required to work evenings and weekends.