Provider Service Representative

GENERAL DESCRIPTION:
Responsible for answering and making telephone calls to participating and non-participating providers offering services in the service area and outside the plan service area, as well as to policyholders. Guarantees that situations or service needs are solved at the time of the call and, if necessary, refer to their supervisor any situation that cannot be solved according to established operational processes and service guidelines.
ESSENTIAL FUNCTIONS:
•Accurately documents, investigates, and facilitates resolution of complex inquiries related to benefits interpretation, provider configurations, claim edits, eligibility determinations, and Coordination of Benefits (COB), coordinating with internal departments as needed to ensure timely, accurate, and compliant resolution for members and policyholders.
•Serves as the primary point of contact for provider-related service inquiries and issues, supporting Primary Care Physicians, Specialists, Subspecialists, Dentists, Allied Health Providers, Laboratories, and Hospitals,



both participating and non-participating, within the MCS Classicare and MCS Life Networks.
•Ensures confidentiality, security, and proper handling of sensitive information by maintaining full compliance with the Health Insurance Portability and Accountability Act (HIPAA), data privacy policies, and all applicable regulatory and company guidelines throughout all customer interactions and system usage.
•Educates providers and their staff on effective use of provider platform tools, including system access, account creation, access recovery, account unlocking, and available functionalities, ensuring efficient and seamless provider engagement.
•Provides feedback and participates in continuous improvement initiatives by identifying service gaps, recurring issues, or process inefficiencies observed during customer interactions, contributing to enhancements in service quality and operational performance.
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📌 Provider Service Representative (San Juan)
🏢 MCS Healthcare Holdings, LLC (MCS)
📍 San Juan