Provider Services - Provider Services Representative 115-1030

Provider Services Representative

The Provider Services Representative supports the internal infrastructure of the Provider Relations department by managing provider lifecycle processes and maintaining operational efficiency. This administrative role ensures timely and accurate updates to provider records, coordinates credentialing and termination workflows, and responds to routine inquiries from provider offices and internal teams. The Provider Services Representative plays a critical role in supporting smooth internal operations and ensuring data integrity across systems. Serves as the liaison between the provider community and the health plan.

Key Responsibilities:

• Serves as the primary administrative role for internal ticketing processes for provider credentialing, demographic updates, and terminations
• Coordinate internal process and procedures among departments to ensure network, contract, operational procedures are appropriately reflected in our systems and processes.
• Participate in departmental processes established to ensure accurate and timely contracting, credentialing and loading of providers.
• Researches and responds to provider office inquiries received via calls and emails concerning directory listings, participation status and general administrative concerns (e.g., benefits, claims, reimbursement and member issues) and recommends appropriate actions to the requesting party.
• Coordinates with internal departments (e.g., claims, quality, pharmacy, compliance) to resolve provider-elevated operational issues.
• Works in tandem with Provider Services Representative External (Education & Engagement) to resolve complaints & grievance issues and documents appropriately
• Assist contracting in all phases of the Contracting process established by CommunityCare Managed Healthcare Plans of Oklahoma. Processes may include communication with provider during negotiation through completion of executed document implementation of contract, and on-going contract deliverables. Participate in the development of networks and key geographical areas as needed.
• Participates in special projects and assignments as directed, including the development of new/improved operating procedures.
• Job may contain dimensions that could affect performance of responsibility, which may involve dealing with members who are sensitive and/or emotional.
• Perform other duties as assigned.

Qualifications:

• Possess strong oral and written communication skills for interdepartmental and external communication.
• Strong organizational and time management skills; attention to detail is essential.
• Ability to monitor and assess rapidly changing information.
• Ability to think quickly and respond tactfully to sometimes difficult issues in dealing with providers.
• Ability to work independently while managing multiple tasks and meeting deadlines.
• Proficient in Microsoft applications (especially Excel, Outlook)
• Successful completion of Health Care Sanctions background check.

Education/Experience:

• Associate's degree required; Bachelor's degree preferred OR each year of work experience in a healthcare or managed care setting can be substituted for each year of college not completed.
• One to three years of industry related experience in managed care, insurance, physician environment or related area.
• Customer Service or sales-related experience preferred.

CommunityCare is an equal opportunity at will employer and does not discriminate against any employee or applicant for employment because of age, race, religion, color, disability, sex, sexual orientation or national origin