Provider & Member Services Specialist

Job Description

Job Description

The Provider and Member Services Specialist serves as a primary point of contact for providers, members, and third-party administrators (TPAs) regarding provider network participation, claims repricing inquiries, and general network services. This role is responsible for accurately identifying and routing inquiries related to network participation, benefits, eligibility, claim status, precertification, and other plan administration functions to the appropriate internal team or external partner.

 

In addition to call-handling responsibilities, this position provides operational support across multiple areas, including claims, eligibility, provider data management, and special projects. The ideal candidate is adaptable, customer-focused, detail-oriented, and capable of supporting a variety of operational functions as business needs evolve.

 

Roles and Responsibilities

 

Call Handling and Customer Support

• Manage inbound call volumes efficiently while maintaining established performance, quality, and service standards.
• Document interactions accurately and ensure inquiries are resolved or routed to the appropriate internal team or external partner.
• Utilize multiple systems, provider directories, and operational tools to research and support inquiries.
• Escalate complex issues appropriately to Claims, Provider Data, Network Management, or other internal teams.

Claims and Eligibility Support

• Develop foundational knowledge of claims repricing and eligibility workflows to support members, providers, and internal departments when needed.

Provider Data Support

• Assist with provider data maintenance, provider directory updates, network participation research, and data validation activities.

Work Quality and Accuracy

• Demonstrate strong attention to detail and ensure all information communicated to providers, members, and TPAs is accurate and complete.
• Maintain compliance with established procedures, quality standards, and confidentiality requirements.

Productivity and Schedule Adherence

• Maintain consistent attendance and adherence to assigned schedules to ensure adequate support coverage.
• Effectively balance phone responsibilities with operational assignments, follow-up activities, and project work.
• Provide flexible support across operational functions and special projects as assigned based on departmental priorities and business needs.

 

Education and Qualification Requirements

 

• High school diploma required; college degree preferred.
• Previous customer service experience required; experience in a healthcare, insurance, employee benefits, provider network, or medical office environment preferred.
• Healthcare claims, medical billing, provider network, or insurance experience is preferred.
• Demonstrated willingness and ability to learn healthcare claims, eligibility, provider network, and operational processes.
• Excellent verbal and written communication skills, with the ability to adapt communication style based on the needs of the caller.
• Strong customer service skills and a genuine desire to help others.
• Strong attention to detail and ability to accurately document and communicate information.
• Proficiency with Microsoft Office applications and the ability to learn and navigate multiple operational systems.
• Ability to work effectively in a fast-paced, cross-functional environment.
• Strong critical-thinking and problem-solving skills, with a willingness to learn and adapt to new ideas and processes.
• Ability to manage multiple priorities and balance phone responsibilities with operational assignments and project work.
• Strong team player with a positive attitude and professional demeanor, including appropriate appearance and conduct.
• Bilingual skills preferred, but not required.

\nCompany Description

Healthcare Highways challenges the status quo of traditional carrier networks to bring competition, flexibility, and cost efficiency to employer-sponsored healthcare. We design, manage, and operate medical provider networks, with a core focus on high-performance networks built from curated providers who meet strict quality standards and agree to negotiated rates.

We also work directly with employers to execute their network strategy, supporting domestic network management and steerage, direct contracting, and out-of-network repricing. The result is high-quality care for local employers, with lower costs for both businesses and their employees.

We foster a collaborative, innovative, and inclusive workplace where creative and analytical thinkers thrive. At Healthcare Highways, candor, integrity, and teamwork are at the core of everything we do. We invest in our employees' growth and professional development by offering competitive compensation, career advancement opportunities, and a strong commitment to work-life balance.

A career at Healthcare Highways means being part of a forward-thinking organization transforming healthcare. If you're passionate about impacting employers, providers, and the communities we serve, we invite you to join our mission. Explore opportunities and join our team today at Healthcare Highways Careers.

Company Description

Healthcare Highways challenges the status quo of traditional carrier networks to bring competition, flexibility, and cost efficiency to employer-sponsored healthcare. We design, manage, and operate medical provider networks, with a core focus on high-performance networks built from curated providers who meet strict quality standards and agree to negotiated rates.\r\n\r\nWe also work directly with employers to execute their network strategy, supporting domestic network management and steerage, direct contracting, and out-of-network repricing. The result is high-quality care for local employers, with lower costs for both businesses and their employees. \r\n\r\nWe foster a collaborative, innovative, and inclusive workplace where creative and analytical thinkers thrive. At Healthcare Highways, candor, integrity, and teamwork are at the core of everything we do. We invest in our employees' growth and professional development by offering competitive compensation, career advancement opportunities, and a strong commitment to work-life balance.\r\n\r\nA career at Healthcare Highways means being part of a forward-thinking organization transforming healthcare. If you're passionate about impacting employers, providers, and the communities we serve, we invite you to join our mission. Explore opportunities and join our team today at Healthcare Highways Careers.