Provider Call Center Business Specialist

Employment Type
Full-time

Exempt or Non-Exempt
Exempt

Job Summary
Pay Range
: $47,500 to $88,000

Note
: Individuals typically begin between the minimum to middle of the pay range

The Provider Call Center Specialist reports to the Provider Call Center Liaison and is responsible for providing support and audit oversight for the Provider Call Center. The specialist will collect, analyze, and report performance data for the Provide Call Center while working with HMSA staff and the vendor team to assess and streamline operational processes. In this role, the specialist will actively work with necessary departments to resolve issues raised through provider inquiries via HHIN and/or the Call Center.

Minimum Qualifications

• Bachelor's degree and two years of related work experience; or equivalent combination of education and work experience.
• Effective verbal and written communication skills
• Strong project and process management skills
• Basic knowledge of Microsoft Office applications including Word, PowerPoint, Excel, and Outlook.

Duties And Responsibilities

• Collect, analyze, and utilize data and feedback related to the Provider Call Center to provide audit oversight upon predefined contractual criteria and identify opportunities to improve operations between HMSA and the vendor team. This will include direct communication and participation with the Vendor Management Office (VMO) and Transformation Management Office (TMO). Compile reports about incidents, events, and updates regarding provider HHIN and phone inquiry issues and provide database management for any escalations.

• Gathers, reviews, and analyzes information to identify trends, issues, and potential problems and solutions related to development and implementation, including but not limited to new products or services, contract deliverables, enhancements to add functionality and/or redesigns of systems, both manual and automated, to improve efficiency, financial models of costing and pricing. This includes reviewing and validating new implementations.

• Initiates the development of strategies and tactics based on logical assumptions and facts considering resources, constraints, and HMSA values. Provides critical assessments of information and data about current trends and issues and actively and openly shares with appropriate parties to encourage collaboration for improvement and change. Translates analysis into solutions and/or options for consideration of specific HMSA actions, including business process improvements.

• Conducts ongoing research and analysis to assess changing needs of our industry. Provides quality, objective, and professional analysis. Initiate change and evaluate impact.

• Communicate with vendor team and internal stakeholders to quickly and accurately obtain or provide information regarding HHIN inquiry and provider call updates.

• Works directly with cross-departmental team members to complete tasks and provide status updates. Works with the project team, HMSA departments and external partners to monitor, collect, communicate, and distribute information.

• Communicates analysis, assessments, recommendations and completed work product through professional written and verbal reports and presentations. Conducts presentations to all levels of the organization (unit meetings, department meetings, management meetings, etc.) and our vendor partner to ensure reporting of quality outcomes are consistent and understood.
• Provides guidance and assistance to the vendor team to ensure training programs are up-to-date and effective.
• Communicate process changes to vendor to stay current with government and commercial health plans, agencies and other entities' guidelines.

• Engages and collaborates with project staff and subject matter experts with the planning and implementation of project and sub project work efforts. Supplies or advises in the development of requirements, reports, budgets, and other analyses, and help solve operational issues and roadblocks.

• Organize, maintain, and keep readily accessible, all references, documents, policies, and procedures to ensure accuracy on the part of the vendor.

• Read, analyze, and interpret business documents such as HMSA's Medical Policy Manual, plan certificates and Guide to Benefits, statistical data, product development memos and documents published by Blue Cross and Blue Shield Association related to program compliance; the Federal and/or state governments pertinent to the business (i.e. Federal Register, CMS guidelines, Hawaii Revised Statutes (H.R.S). Work collaboratively with the Customer Relations Content Administrator to ensure online resources are up to date.

• Ensures all appropriate processes are followed and documentation is completed as required by acting as quality control checkpoint verifying standards are adhered to.

• Proactively resolve issues that could impact providers and members and providers.

• Maintain knowledge of current health plan and agency requirements.
• Performs all other miscellaneous responsibilities and duties as assigned or directed.