Healthcare Customer Service Advocate

Healthcare Customer Service Advocate

Work Setup: Onsite for the first 6 months, then remote after successful completion of training, nesting, etc., depending on performance

Location: Valero, Makati City
Work Hours: Night Shift/Graveyard Shift

Job Summary

The Healthcare Customer Service Advocate - Provider Services is responsible for delivering accurate, timely, and professional support to healthcare providers and billing representatives regarding eligibility, claims, payments, appeals, Explanation of Benefits (EOBs), and other provider-related inquiries.

The Advocate serves as a primary point of contact for providers and is accountable for accurately researching and resolving inquiries within the established scope of responsibility, properly documenting all interactions, and escalating or transferring issues that require additional support.

This role is responsible for meeting established productivity, quality, attendance, schedule adherence, service-level, customer experience, compliance, and other account-specific Key Performance Indicators (KPIs). Employees must successfully complete all required training, assessments, certification, nesting, and graduation requirements before becoming eligible to work remotely.

Key Responsibilities

Provider Service & Production

• Serve as a primary point of contact for healthcare providers and billing representatives regarding provider-service inquiries.


• Handle assigned provider interactions through applicable channels, including phone, email, fax, web inquiries, and other designated communication channels.


• Research and respond to inquiries regarding member eligibility and applicable benefit information; claim status and outcomes; payments; EOBs; appeals; required or missing documentation; stop payments; check reissuance; payment tracers; copies of cashed checks; and upheld or late-submission letters, as applicable to the assigned scope.


• Accurately research applicable systems and approved resources before providing information to a provider.


• Resolve inquiries within the Advocate's established scope of responsibility and appropriately escalate or transfer matters outside the authorized scope.


• Follow established escalation and transfer procedures and maintain ownership of the interaction through resolution or proper handoff.


• Meet established individual production requirements and applicable service-level, turnaround-time, and productivity expectations.

Quality & Accuracy

• Meet or exceed established individual quality requirements for all provider interactions and production work.


• Provide complete, accurate, and consistent information based on approved client documentation, policies, procedures, and system information.


• Follow required workflows and procedures without unauthorized deviation.


• Accurately and completely document every provider interaction and all actions taken in the appropriate system(s).


• Participate in routine QA monitoring, coaching, calibrations, and performance-improvement activities.


• Review and acknowledge QA results, complete required corrective actions within established timelines, and demonstrate sustained improvement following coaching.


• Immediately escalate potential compliance concerns, process discrepancies, or situations that could result in incorrect information being provided to a provider.


• Maintain a Zero Error Mindset focused on preventing avoidable errors and protecting the provider and member experience.

Productivity & KPI Expectations

• Consistently meet all established account KPIs, including productivity, quality, attendance, schedule adherence, service level, documentation accuracy, transfer/escalation expectations, turnaround time, customer/provider experience, training, certification, and compliance requirements.


• Maintain performance at or above established account standards after graduation and throughout employment.


• Take ownership of individual performance results and promptly address identified performance gaps.


• Understand that KPI requirements may be updated based on client requirements, operational needs, or changes to the scope of work.

Training, Certification & Graduation

• Successfully complete all required new-hire orientation, structured curriculum and training modules.


• Complete required Process Knowledge Tests (PKTs), role-playing, mock calls, simulations, and other skills assessments.


• Complete QA training and demonstrate an understanding of the QA standards and audit criteria used to evaluate performance.


• Successfully complete required certification, nesting, production-readiness requirements, and formal graduation criteria before independently handling production work and before becoming eligible for remote work.


• Successful completion of classroom training alone does not constitute graduation or approval for remote work.


• Complete required refresher training, workshops, boot camps, ongoing PKTs, certifications, and recertifications as assigned.


• Maintain current knowledge of client requirements, process changes, system updates, and operating procedures.

New-Hire Performance

• Following graduation, performance will continue to be closely monitored through the first 90 days in production.


• New-hire monitoring may include productivity, QA scores, post-training PKT results, individual errors, attendance, schedule adherence, coaching results, and overall progression.


• Employees who do not demonstrate expected progression may be assigned additional coaching, refresher training, targeted development, performance-management actions, and/or may be required to work onsite.

Provider Experience & Communication

• Deliver professional, courteous, confident, and solution-oriented service during every provider interaction.


• Communicate healthcare claims and benefit information clearly and accurately.


• Demonstrate active listening and appropriate probing techniques to fully understand the provider's inquiry before responding.


• Avoid unnecessary transfers by researching and resolving inquiries within the established scope whenever possible.


• Clearly explain next steps when an issue cannot be immediately resolved.


• Maintain professionalism during difficult, escalated, or complex provider interactions.

Compliance & Security

• Follow HIPAA requirements and all applicable privacy, security, confidentiality, client, and Imagenet standards.


• Complete required caller/provider verification before accessing, discussing, or disclosing protected information.


• Access only information necessary to perform assigned job responsibilities.


• Immediately report suspected privacy, security, compliance, or unauthorized-access concerns.


• Maintain accurate and complete records of provider interactions in designated systems.

Coaching & Performance Management

• Participate in scheduled one-on-one meetings, coaching sessions, performance reviews, and development discussions with the Team Lead.


• Review and understand individual productivity, quality, attendance, adherence, and other applicable performance results.


• Take ownership of identified performance gaps and complete assigned corrective actions.


• Demonstrate sustained improvement following coaching, retraining, or other performance interventions.


• Participate in refresher training, workshops, boot camps, or recertification when performance results indicate additional development is required.

Qualifications

• High school diploma or equivalent required; college degree or relevant post-secondary education is an advantage.


• At least 4 years of experience in a healthcare contact center, provider services, claims support, or comparable healthcare operations environment.


• Working knowledge of healthcare claims, EOBs, appeals, eligibility, benefits, and payment processes.


• Ability to research and interpret claim and provider information accurately.


• Strong analytical, problem-solving, multitasking, organizational, verbal, and written communication skills.


• Strong attention to detail and demonstrated commitment to accuracy.


• Ability to work in a metrics-driven environment and consistently meet established productivity and quality requirements.


• Proficiency with Microsoft Office and online systems; ability to learn and navigate multiple healthcare and client systems.


• Experience with Monday.com and AWS Connect is highly preferred.


• Ability to work flexible schedules, including nights, weekends, and holidays, based on client coverage requirements.

Performance Accountability

Employees are accountable for meeting the performance expectations of the position regardless of work location. Remote work is contingent upon sustained performance and compliance with all applicable requirements. Failure to meet established KPIs may result in coaching, retraining, performance management, return to onsite work, or other appropriate action in accordance with company policy.

Ready to Grow Your Career?

We’d love to meet you! Click “Apply Now” and tell us why you’d be a great addition to the ImageNet team.

COMPANY OVERVIEW:

ImageNet is a leading provider of back-office support technology and tech-enabled outsourced services to healthcare plans nationwide. ImageNet provides claims processing services, including digital transformation, claims adjudication and member and provider engagement services, acting as a mission-critical partner to these plans in enhancing engagement and satisfaction with plans’ members and providers. 

The company currently serves over 70 health plans, acting as a mission-critical partner to these plans in enhancing overall care, engagement and satisfaction with plans’ members and providers.  The company processes millions of claims and multiples of related structured and unstructured data elements within these claims annually.  The company has also developed an innovative workflow technology platform, Jetstream TM, to help with traceability, governance and automation of claims operations for its clients.

ImageNet is headquartered in Tampa, operates 10 regional offices throughout the U.S. and has a wholly owned global delivery center in the Philippines.