Provider Relations Job Description

Provider Relations Job Description

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Provider relations provides information to Passport Health Plan to assist in the processing of claims, including reports, claims denial reasons and claims impact analyses.

Provider Relations Duties & Responsibilities

To write an effective provider relations job description, begin by listing detailed duties, responsibilities and expectations. We have included provider relations job description templates that you can modify and use.

Sample responsibilities for this position include:

Sorts through mail, separates by client and identifies Provider Relations mail
Utilizes software system to search for original EOB, matches mail to EOB and attaches to correct file
Photocopy documents and fee schedules as needed
Retrieves voicemail messages and forwards to appropriate Provider Relations Representative
Provides the highest level of customer service to current or prospective clients of the Company, vendors, staff, business partners or visitors
Identifies problems, provides solutions and resolves promptly
Manages confidential client, information with discretion and good judgment in accordance with department and Company guidelines
Overseeing staff responsible for the organization's provider network and contracts to ensure provider satisfaction, adequate networks, and departmental efficiency
Hiring and retention of quality staff and the on-going planning, monitoring, training, coaching, evaluation, and appraisal of staff performance and development to ensure successful achievement of goals and objectives
Developing, planning, and implementing provider and network strategies to insure the development, maintenance, and growth of a network of providers sufficient to ensure provision of the contracted benefits and the achievement of medical cost targets

Provider Relations Qualifications

Qualifications for a job description may include education, certification, and experience.

Licensing or Certifications for Provider Relations

List any licenses or certifications required by the position: ITIL, PMP, BLS, FEMA, PMI, RN, BSN, SMG, AWS, V3

Education for Provider Relations

Typically a job would require a certain level of education.

Employers hiring for the provider relations job most commonly would prefer for their future employee to have a relevant degree such as Bachelor's and Master's Degree in Education, Business, Management, Healthcare, Healthcare Administration, Health, Performance, Business/Administration, Health Care Administration, Marketing

Skills for Provider Relations

Desired skills for provider relations include:

CMS and state regulations
Medicaid
Claims processing systems and guidelines
Healthcare delivery
Provider and payor roles
Responsibilities and challenges
Claims processing
Various quality programs
Claim processing systems and guidelines
Dental products/providers

Desired experience for provider relations includes:

Developing and retaining effective relationships with physician and business leadership of key physician groups, the organization's vendors, ancillary providers, and delivery systems to drive business results
Acting as a liaison and managing the relationship between government agencies and the organization's regarding provider network issues
Investigating and resolving complex and/or escalated provider questions, complaints, claims and claims payments inquiries, and provider non-compliance with Access and Availability standards issues
Co-chairing the Complaints and Appeals Sub-committee
Meet with key hospital, physician group, and community-based providers on a regular basis
Assist in marketing initiatives to reach membership goals

Provider Relations Examples

1

Provider Relations Job Description

Job Description Example
Our innovative and growing company is looking to fill the role of provider relations. Thank you in advance for taking a look at the list of responsibilities and qualifications. We look forward to reviewing your resume.
Responsibilities for provider relations
  • Research and resolve provider escalation issues and manage work items through department queues
  • Outreach to provider offices via phone and email to support the revalidation initiatives
  • Educate provider offices via phone and email concerning the provider enrollment and credentialing process
  • Support any department administrative requirements including preparing educational documents, organizing webinars, tracking participation in various educational sessions, and supporting other reporting needs
  • Participates in network and company meetings, including physician board of directors, quality management, financial, operations
  • Ensures demographic information and facility point of contacts (POCs) are accurate by verifying during each provider/facility contact
  • Ensures all practitioners, groups and facilities are properly credentialed and are processed within required time-frames
  • Develop and maintain positive relationships with assigned corporate and high-volume providers through effective and ongoing communication, training and providing timely feedback
  • Negotiate provider rates for all assigned providers as required
  • Develop and maintain strategic partnerships with key corporate providers
Qualifications for provider relations
  • Participate in activities that help others achieve their full potential
  • Execute preferred provider strategy and guidelines to foster optimum access to appropriate network providers and facilities
  • Provide timely follow-up to customer inquiries and facilitate resolution of issues
  • Bachelor’s Degree or one to two years equivalent business, contracting, customer relations and/or Tricare experience
  • Advanced computer proficiency and skills in MS Excel, PowerPoint, and Word required
  • Facilitative skills
2

Provider Relations Job Description

Job Description Example
Our innovative and growing company is searching for experienced candidates for the position of provider relations. Thank you in advance for taking a look at the list of responsibilities and qualifications. We look forward to reviewing your resume.
Responsibilities for provider relations
  • Maintain up-to-date knowledge about provider network and provider utilization
  • Support the Contact Center as needed with difficult to fill cases by suggesting alternative solutions and/or reaching out to providers directly to ensure quality care
  • Ensure a strong line of communication with team responsible for the daily transactional work required to support the BUCA providers that the manager is assigned to
  • Participate in the maintenance of provider files
  • Answer incoming calls from providers (physicians), workers comp insurance adjusters, and injured workers
  • Resolve issues received from phone calls and our web portals
  • Send written responses
  • Supervise the activities of analysts and specialists for Provider Relations, Provide Support, and Provide Enrollment and Credentialing (PEC)
  • Coordinates and implements credentialing activities to assist providers with the completion of applications for network contract offerings
  • Assist with coordination, education and outreach
Qualifications for provider relations
  • Previous experience in provider contracting or provider services
  • Required 3+ years of experience in Management, Supervisory, or Lead/Sr
  • Bachelor's Degree in business, healthcare administration, or public health administration
  • Other healthcare or sales equivalent experience will be considered in lieu of Degree
  • 5+ years in a health care marketing or sales manager role or business development
  • Understand the practice of medicine including referral relationships, payer requirements, and other economic and clinical influences
3

Provider Relations Job Description

Job Description Example
Our innovative and growing company is searching for experienced candidates for the position of provider relations. Please review the list of responsibilities and qualifications. While this is our ideal list, we will consider candidates that do not necessarily have all of the qualifications, but have sufficient experience and talent.
Responsibilities for provider relations
  • Work with management team to formulate effective strategies to improve provider performance
  • Commercial encounter per member per year
  • Access & Availability metrics
  • Appropriate utilization of Emergency Room
  • Out of network utilization
  • Increase channeling of Gastrointestinal procedures to Ambulatory Surgery Centers
  • Ensures the smooth operation and administration of pharmacy provider agreements
  • Manages SOC compliance for CPBA Provider Relations
  • Manages national database of pharmacies
  • Design, edit, format, and produce communications on tight deadlines
Qualifications for provider relations
  • IPA, ACO, MSO, or other relevant experience
  • Experience in physician relations or managed care
  • Calls and claims experience
  • Excellent written and verbal communication skills excellent phone manner
  • Word and Excel at an intermediate level
  • HTML programming, Web site development skills and familiarity with KP database systems desirable
4

Provider Relations Job Description

Job Description Example
Our growing company is looking to fill the role of provider relations. To join our growing team, please review the list of responsibilities and qualifications.
Responsibilities for provider relations
  • Work in partnership with the territory manager to ensure all territory needs are being met
  • Primarily responsible for ensuring provider records and documentation are up to date, accurate and accessible
  • Maintain accurate, detailed and complete record of activities related to the ongoing communication with providers including, but not limited to phone interactions, communications sent electronically and in hard copy and status of relationships
  • Obtain and maintain all required documentation from providers in order to keep accurate and complete contract records for all assigned providers
  • Develop and maintain positive relationships with company’s network of contracted providers within assigned region through ongoing communication, training and providing feedback from client employees
  • Support the Provider Relations Manager in assigned region to develop and maintain strategic partnerships with key corporate providers and their franchised locations to ensure the highest quality care at the lowest possible price
  • Determine and implement appropriate solutions for provider maintenance requests, client complaints, and billing issues
  • When requested by the territory manager, negotiate fiscally responsible provider rates
  • Support the Contact Center with difficult to fill cases by suggesting alternative solutions and/or reaching out to providers directly to ensure quality care
  • Contact potential vendors/providers we have requested to join the GVRA provider network
Qualifications for provider relations
  • Strong analytical and organizational skills also required
  • Excellent customer service skills with the ability to make independent judgments, handle multiple projects simultaneously, adapt to shifting priorities and utilize time management skills to meet deadlines
  • Ability to work with a diverse group of people, including physicians, support staff, coworkers and management
  • Is tactful and diplomatic
  • Demonstrated ability to research issues and bring about resolution either directly or with the assistance of others
  • Some travel within Northern California service area and/or statewide may be required
5

Provider Relations Job Description

Job Description Example
Our growing company is searching for experienced candidates for the position of provider relations. To join our growing team, please review the list of responsibilities and qualifications.
Responsibilities for provider relations
  • Initiate responses to service provider requests, needs, updates/ and concerns
  • Initiate negotiation of provider/vendor contracts, service agreements (services, terms, and pricing)
  • Complete requisitions in PeopleSoft Financials for contract renewals
  • Schedule and conduct/participate in quarterly provider visits
  • Provide input for the provider manual
  • Communicate any new or updated information regarding service provision to service providers/vendors
  • Maintain the Provider Directory by Quadrants and provide to GVRA/VR staff monthly
  • Ensure all providers /vendor information is up to date in GRACI System
  • Complete the vendors request approvals submitted by GVRA/VR staff in GRACI
  • Process payments for Community Rehabilitation Programs in GRACI
Qualifications for provider relations
  • Currently enrolled as a Junior, Senior or Graduate student in an accredited college program with course work related to the internship with a minimum 3.0 GPA
  • Bachelor’s degree in Business Administration, Customer Service, or related field, required
  • Ability to travel up to 50% within the territory of the greater Austin and San Antonio areas across the United States for team and personal development
  • The incumbent must be enrolled in a degree program from a college or university or recent graduate
  • Typically, this internship would occur after the student has taken most of the courses required by the degree program
  • Where applicable - the degree program must require an internship as a graduation requirement (or offer as a credit option

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