At Triple-S, we are committed to providing meaningful job experiences for Valuable People (Gente Valiosa). We strive for excellence in everything we do, from the way we work together to the way we serve our customers.
When you join Triple-S, you will be key to our efforts on delivering high-quality and affordable healthcare as well as contribute to our purpose to enable healthier lives. We serve more than 1 million consumers in Puerto Rico through our Medicare Advantage, Medicaid, Commercial, Life and Property & Casualty Businesses.
Let's build healthier communities together, join now!
JOB SUMMARY
The Provider Navigator serves as a primary liaison between the Health Plan and its contracted provider network. This role is responsible for supporting providers with operational inquiries, facilitating issue resolution, and ensuring providers are educated on health plan processes, systems, and regulatory requirements. The position plays a key role in enhancing provider satisfaction, operational efficiency, and overall network performance.
ESSENTIAL FUNCTIONS
- Serve as the primary point of contact for assigned providers, physician groups, and ancillary providers.
- Guide providers through health plan processes including credentialing and recredentialing, contracting and amendments, claims submission and payment inquiries, prior authorization and referral processes, provider portal and system navigation, track and resolve provider issues through to closure, ensuring timely follow-up.
- Educate providers on health plan policies, workflows, and updates.
- Conduct outreach related to: new provider onboarding, process changes and system enhancements, regulatory and compliance requirements, support provider adoption of electronic tools and self-service resources.
- Respond to and resolve provider inquiries related to contracting, credentialing, claims, authorizations, referrals, eligibility, and provider portal access.
- Coordinate with internal departments (Claims, Credentialing, Utilization Management, Compliance, IT) to resolve complex issues.
- Track and document provider cases through resolution within CRM or tracking systems.
- Support provider satisfaction initiatives and engagement strategies.
EDUCATION
- Bachelor's Degree in Healthcare or Business
EXPERIENCE
Bachelor’s Degree (BD), preferably in Healthcare Administration, Business, Public Health or related field. One (1) to three (3) years of experience in health insurance operations, provider relations, claims administration, and/or managed care environment.
LICENSES AND CERTIFICATIONS
- None required
COMPETENCIES
- Action Oriented
- Collaborates
- Customer Delight
- Instills Trust
- Manages Ambiguity
It is company policy to seek for the qualified applicants for positions throughout the company without distinction of race, color, national origin, religion, sex, gender identity, real or perceived sexual orientation, civil status, social condition, political ideologies, age, physical or mental disability, veteran status or any other characteristic protected by law. Drug-free company.
Equality Employment Opportunity/Affirmative Action for People with Disabilities/Veterans. Employer with E-Verify to verify the eligibility of employment of all the new employees.
We encourage Veterans and Disabled to Apply.