Senior Provider Service Representative

Optum is a global organization that delivers care, aided by technology, to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data, and resources they need to feel their best. Here, you will find a culture guided by diversity and inclusion, talented peers, comprehensive benefits, and career development opportunities. Come make an impact on the communities we serve as you help us advance health equity on a global scale. Join us to start Caring. Connecting. Growing together. 

This is a critical position within the Provider Services Department and a required position within our contract budget.  This is a budgeted replacement position that is funded by the ASO contract with the County of San Diego.  The position is critical to maintaining the Fee for Service Provider Network that we manage on behalf of the County. This position is responsible for processing the provider applications & contracts, completing the provider credentialing and re-credentialing. 

The Senior Provider Services Representative role is focused on managing provider networks that support the client base, including hospital, FFS and TERM networks. Responsibilities may include provider relation activities, analyzing provider performance, credential and recredentialed activities, and creating provider reimbursement arrangements.  Demonstrates thoroughness and attention to detail to reviewing tasks and documents. Proactively engages in effective communication with diverse audiences and providers. Maintains tasks accuracy especially under tight work deadlines.  Consistent with productivity goals and departmental expectations.

Responsible for the full range of provider relations and service interactions. Works with Manager of Provider Services on processing applications and related documents; completing credentialing process in conjunction with Corporate Credentialing Department staff. Maintains and ensures the integrity of provider databases; responds to provider inquiries and provides exceptional customer service to providers, County partners, peers, staff in other departments and the general public.  The Contract Administrator may work with providers on the TERM, and/or Medi-Cal Fee-For-Service (FFS) Network(s) as well as Off Panel, Out of Network providers, Skilled Nursing Facilities, Hospitals, which includes the San Diego County Psychiatric Hospital and/or Edgemoor Hospital, as well as other medical professionals.

Location: This role will require working 2 days onsite at 3131 Camino del Rio North, Suite 700, San Diego CA, 92108. If you reside in San Diego, CA, you will enjoy the flexibility of a hybrid-remote* role as you take on some tough challenges.

Schedule: Monday-Friday, 8:30am-5pm PST

Primary Responsibilities: 

• The role in this function is accountable for the full range of provider relations and service interactions within UHG, focusing on end-to-end provider claims, call quality, and network support
• Manage provider interactions and ensuring ease of the provider portal, including future service enhancements
• Supports the development and delivery of external provider education and training programs
• Assist the Manager and Leadership in updating and developing provider data, workflows, systems, and other processes
• Supports credentialing, recredentialing, enrollment and contracting processes, including Letters of Agreement (LOAs) ensuring compliance with NCQA or County standards
• Orders and supports Primary Source Verification for Providers
• Oversees and maintains updated provider credentialing documentation, including but not limited to DEA registration, clinical license, board certifications, and PLI
• Completes administrative processes related to the applications and supporting documents to ensure compliance with credentialing criteria for inclusion in the FFS and TERM provider networks
• Collaborates with cross-functional teams to ensure seamless execution of site-wide processes
• Responds to provider requests (emails, calls, mail correspondence, and faxes) and inquiries and direct them to appropriate internal or external resources
• Designs and implements programs to build and nurture positive relationships between the health plan, providers (physician, hospital, ancillary, etc.), and practice managers
• Contributes to the development and management of provider network strategies
• Identifies gaps in