Provider Representative Job Description

Provider Representative Job Description

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Provider representative provides support to Network Contracting, Payment Integrity, Health Services, and other internal departments related to Harvard Pilgrim reimbursement methods, fee schedules, policies, and Medicare methodologies.

Provider Representative Duties & Responsibilities

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

Sample responsibilities for this position include:

Interact in a professional, respectful and helpful manner
Continue professional growth and development
Complete deliverables in a timely fashion
Generate call and visit reports daily and document all practice encounters
Exercise their best judgment when reviewing an order to determine whether or not it will be finalized as revenue or non-revenue
Review pre-authorization denial and determine if an appeal is necessary
Work with multiple parties to designate pre-authorization orders
Perform on-site visits to participating providers to offer continued education and training
Coordinate and conduct provider recruitment activity, network analysis
Update participating providers regarding new policies and procedures

Provider Representative Qualifications

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

Education for Provider Representative

Typically a job would require a certain level of education.

Employers hiring for the provider representative job most commonly would prefer for their future employee to have a relevant degree such as Associate and High School Degree in Business, Education, Healthcare, Health Care, Associates, Communications, Management, Health Care Administration, Healthcare Administration, Marketing

Skills for Provider Representative

Desired skills for provider representative include:

EMR for recording patient visits
ICD10
Billing / claims submission and other related actions
Managed care and Medicare concepts
Managed Care and Medicare programs
Pivot tables
Vlookup
BCBSKS in relationship to our operative philosophies and reimbursement methodologies
Basic benefit structures

Desired experience for provider representative includes:

Review existing policy to ensure maximum compliance, troubleshoot issues raised by provider and distribute any needed material
Identify non-compliant providers, and providers with member complaints
Communicate provider specific problems to management and propose remedy
Keep abreast of departmental specific goals and reinforcing these goals to providers
Maintain accurate records of contacts and reports
Plan, organize and conduct educational training seminars for the assigned provider network

Provider Representative Examples

1

Provider Representative Job Description

Job Description Example
Our innovative and growing company is hiring for a provider representative. To join our growing team, please review the list of responsibilities and qualifications.
Responsibilities for provider representative
  • Provide support and training on the use of web-based services
  • Provide timely, accurate, and courteous responses to a high volume of telephone inquiries from both members and providers
  • Achieve and maintain productivity and quality performance expectations
  • Interpret and effectively communicate benefits and eligibility information to our customers
  • Manage pending inventory in a timely and accurate manner in order to meet or exceed quality and productivity standards
  • Provide timely follow-up with other internal departments to expedite resolution of difficult/aging inquiries, and when necessary escalate those issues to management for further handling
  • Keep abreast of all system, contractual, compliance standard changes and policy updates, and attend additional training sessions as necessary
  • Interact with Claims Dept
  • Inform providers of policy changes and/or new policies that may arise
  • Assist with development and distribution of Provider Manual
Qualifications for provider representative
  • Microsoft Word is required *LI-RG1
  • Assist the Director of Provider Services with reports, projects, and other duties, as appropriate
  • A minimum of 2 years’ provider contracting experience
  • Previous healthcare claims and provider experience strongly preferred
  • Ability to multi-task through multiple system applications while speaking with the customer on the phone
  • Strong attention to detail and ability to prioritize and organize work
2

Provider Representative Job Description

Job Description Example
Our growing company is looking for a provider representative. We appreciate you taking the time to review the list of qualifications and to apply for the position. If you don’t fill all of the qualifications, you may still be considered depending on your level of experience.
Responsibilities for provider representative
  • Assist with writing contracts, amendments and letters of agreements, and other documents and projects as required
  • Perform a variety of other duties as assigned
  • Record all calls and detail
  • Receive requests for adjustments on claim issues
  • Receive requests for disenrollment
  • Execute exceptional critical thinking and analytical skills effective time management to ensure work is completed efficiently and accurately
  • Conducts frequent visits to current and prospective referring physician offices within a regularly scheduled call cycle
  • Manages a specified territory of referral sources
  • Pre-plans and arranges the required number of sales calls per day
  • Utilizes salesforce.com to plan, implement & evaluate sales campaigns
Qualifications for provider representative
  • Uses a variety of references to research and prepare healthcare provider information for loading into the health plan system/database
  • Maintains tracking system of correspondence and outcomes
  • Two (2) to five (5) years of experience in data analysis and reporting, clinical quality measurement, and support for management decision making
  • Experience and demonstrated successful leadership of disease management and/or population health programs
  • Bachelor's degree preferred, high interest in the healthcare field
  • Identifies referral pattern changes and takes action to grow the business and immediate action to address volume loss
3

Provider Representative Job Description

Job Description Example
Our company is searching for experienced candidates for the position of provider representative. 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 representative
  • Responsible for carrying out launch plans for any new imaging center, new modality or service in his/her assigned territory
  • Compiles and frequently reviews marketing plans to ensure specific marketing goals and objectives for his/her territory are attained
  • Directly responsible for procedure volume and changes
  • Fiscally responsible for his/her sales and marketing budget
  • Complies with all State and Federal guidelines for expenditures related to referral sources
  • Assists patients who have managed care or fee for service insurance with their selection of a primary care physician by providing information about available physicians and following CSMG/CSHA policy regarding new patient assignment
  • Answers patients’ questions regarding CSMG/CSHA, its specialty network and contracted hospitals, and care delivery procedures
  • Answers patients’ questions regarding their benefit plans and co-payments and directs patients back to the health plans when necessary
  • Verifies member eligibility via telephone, fax back or through the health plan web site and forwards information to enrollment for documenting in IDX
  • Completes a thorough and accurate registration on each patient, including demographic and insurance information
Qualifications for provider representative
  • Follows departmental procedures for following up with patients for whom complete information was not obtained at the time of contact to ensure an accurate patient record by the time of the appointment
  • Determines patient’s appointment needs and schedules new patient appointment per protocol
  • Confirms patient appointments, as instructed
  • Educates patients about CSMG/CSHA programs and services and directs patients to the Website for further information
  • Serves as liaison to physician practices and other CSMCF/CSMNS departments
  • Acts as the member/provider liaison with the Claims and Physician Billing Departments as needed to resolve any claims/billing issues
4

Provider Representative Job Description

Job Description Example
Our company is growing rapidly and is looking for a provider representative. 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 representative
  • Assists peers and members in the resolution of member and provider problems, complaints and/or grievances
  • Refers patient concerns to supervisor or managers as necessary
  • Ensures phones are covered at all times per policy and procedure
  • Investigates claims
  • Identify issues that result in claims processing errors and resolve
  • Identify, reverse or adjust claims issues
  • Communicate to providers plan policies, coverage and procedures
  • Comprehends Provider contracts, is able to determine capitation terms and effectively incorporate changes and / or updates for configuration
  • Ensures accuracy of data on Excel spreadsheets by verifying proper linking
  • Utilizes various computer programs to research provider, member and eligibility information
Qualifications for provider representative
  • BA/BS degree or equivalent experience, and 3-5 years provider relations experience in a managed care setting
  • Proficient in usage of Microsoft Windows applications
  • Knowledge of health plan programs desirable
  • Excellent ability to plan and organize
  • Performing research on provider inquires
  • Experience with provider information and plan benefits in the insurance industry
5

Provider Representative Job Description

Job Description Example
Our innovative and growing company is looking to fill the role of provider representative. If you are looking for an exciting place to work, please take a look at the list of qualifications below.
Responsibilities for provider representative
  • Maintain accurate data in provider file data systems
  • Maintain and initial setup of assignment accounts (AA) from the AA applications
  • Update group and provider affiliations from AFBs and written requests
  • Maintain accurate data of1099 tax ID updates
  • Maintain accurate data of UPIN/PTAN and/or Medicare Welcome Letter information
  • Maintain accurate data of state license updates
  • Maintain accurate data of Enumerating providers
  • Maintain accurate data of name changes, demographic data updates, specialty changes
  • Maintain accurate data of hospital affiliations, network affiliations, network terminations
  • Maintain accurate data of facility Agreement data, Institutional non-contracted files
Qualifications for provider representative
  • Ability to multitask between programs, data entry and look up systems while speaking with providers
  • Ability to work extended hours and weekends as necessary
  • Flexibility to work at home as business requirements
  • Bachelor's Degree or equivalent Healthcare experience and one (1) year experience in the health care billing or healthcare public relations field (5 years total)
  • Ability to work independently while traveling
  • Must reside in Fulton County or the Atlanta Metro Area

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