| Provider Specialist (Lanham, MD) Summary - The Provider Specialist serves as the primary point of contact for healthcare providers, hospitals, and vendor partners regarding benefit, eligibility, and claims inquiries. This role requires strong communication and problem-solving skills to ensure timely and accurate responses to providers while maintaining compliance with plan provisions, policies, and client service standards. The Provider Specialist plays a key role in fostering positive provider relationships and ensuring the efficient resolution of claim-related issues within a Third-Party Administrator (TPA) environment.
Essential Duties and Responsibilities - Respond to inbound phone calls, emails, and web inquiries from providers regarding claim status, benefits, eligibility, prior authorization, and payment information.
- Research and resolve complex claim inquiries and discrepancies by reviewing plan documents, system records, and claim adjudication notes.
- Process and track provider appeals and reconsiderations in accordance with plan policies and regulatory requirements.
- Document all inquiries and resolutions accurately in the system to ensure proper tracking and follow-up.
- Escalate issues to appropriate internal departments (Claims, Eligibility, IT, Accounting, etc.) for further research or correction as needed.
- Assist providers with portal registration, navigation, and troubleshooting of web-based tools.
- Identify trends or recurring issues impacting provider satisfaction and communicates findings to leadership.
- Support audit requests, reporting, and other administrative duties related to provider relations and claims resolution.
- Maintain confidentiality and adheres to HIPAA and company privacy standards.
- Deliver exceptional customer service by ensuring courteous, professional, and accurate communication in all interactions.
- Regular and predictable attendance is an essential function of this job.
Key Competencies for the Provider Specialist - Customer service excellence
- Problem solving and critical thinking
- Team collaboration
- Accuracy and attention to detail
- Time management
- Confidentiality and professionalism
Education - High school diploma or equivalent, required
- Associate or Bachelor's degree, preferred
Experience - 2+ years of experience in healthcare customer service, claims, or provider relations, preferred within a TPA, insurance carrier, or managed care organization
- Working knowledge of medical billing, coding (ICD-10, CPT, HCPCS), and EOB interpretation, preferred
Skills - Strong verbal and written communication skills
- Proficient in MS Office and claims administration systems
- Detail-oriented with strong analytical and problem-solving skills
- Ability to multitask and manage a high volume of inquiries in a fast-paced environment
- Commitment to delivering high-quality service and maintaining positive provider relationships
Work Schedule - Full time. Monday - Friday, 8:30am - 5:00pm. Required in office (no at-home days). Competitive Benefits and Compensation Package - 13 paid holidays
- Paid Time Off (PTO)
- Pro-rated during first year of employment
- 15 days of PTO provided in the next calendar year!
- Medical, dental and vision insurance, with option for dependent coverage
- Employer-paid basic life
- Long-term disability and short-term disability insurance
- 401(k) with employer match
- Tuition reimbursement
Our Culture BeneSys wants to be a great service provider to the members we serve, and we recognize we can only do that if we are also a great employer with successful employees. In short, our success is driven by our employees’ successes. We want to be a place where people want to work, feel proud of what they do and feel fulfilled both professionally and personally. We want to create a place where employees can find long-term growth and potential. Our culture focuses on three core values: - Collaboration: working together across 31 locations to achieve the best for the company and our clients
- Dedication: striving to create an environment where all employees work toward a common goal while committing to providing the best customer service to our members and our colleagues
- Integrity: doing what we say we will do. Upholding strong ethical and moral principles
ADA & EEO Reasonable accommodations will be made so that qualified individuals with disabilities are able to complete the application process and, if hired, fulfill the essential functions of their job.
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