Responsible for developing and maintaining positive provider relationships with the provider community, by regular on-site visits, communicating administrative and programmatic changes, and facilitating education and the resolution of provider issues.Achieved company targets through implementation of network improvement plans.Completed initial on-board training of newly contracted providers for all applicable product lines within the CalOptima Behavioral Health Network.Functioned as a high level technical resource to resolve or facilitate complex provider operational issues.Developed and delivered presentations on various CalOptima topics to the provider community.

Maintain material in the Provider Manual.Facilitated the review and approval of department policies.Represent CalOptima at provider, community, and health plan sponsored events.Support effective interdepartmental communication.Act as a liaison between CalOptima and the provider community to effectively resolve provider issues.Answer provider phone calls and respond to provider requests, inquiries, and needs in a timely manner.

Prepare, Process, Maintain Medicare Enrollment applications, letter generation and system updates. Handle and analyze inquiries that required additional research or special handling including regulatory issues and complaints which could become grievances.Submit transactions pertaining to members enrollment and eligibility status to the Centers of Medicare Services.Address, verify and resolve member inquiries forwarded by customer service department.Process retroactive enrollments, dis-enrollments, and other reconciliation data and eligibility.

Guide members in understanding and accessing the benefits they are entitled to under Medicare and Medi-Cal, through the OneCare program. Educate providers to help them distinguish between Medi-Cal and Medicare benefits/claims processed through the OneCare program.Assist with coordination of member’s healthcare and social service needs both within and outside the Medical Group and CalOptima. Initiate referrals to both internal and external care management departments and other department/government or community agencies.

Processing member and/or provider information, answering member questions, referring issues to health networks and/or making recommendations for further contacts within CalOptima.Verify member eligibility for providers.Function efficiently and productively in a high volume telephone call center.Maintain departmental productivity standards.Assist data entry and other departments with special projects as needed.