Provider Relations Representative Resume Samples
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Provider Relations Representative Resume Samples
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IN
I Nienow
Ida
Nienow
94914 Treva Greens
Detroit
MI
+1 (555) 912 7924
94914 Treva Greens
Detroit
MI
Phone
p
+1 (555) 912 7924
Experience
Experience
San Francisco, CA
Provider Relations Representative
San Francisco, CA
Dach and Sons
San Francisco, CA
Provider Relations Representative
- Assists in the identification of service level gaps and works with Manager of Provider Relations and Contract Managers to address recruitment opportunities
- Works with providers and network operations to ensure provider data submission and accuracy
- Develop, Assist with delivery of provider education in the following areas related to the contract, specifically with the Waiver provide population
- Relating to the development and management of a provider network,
- Work with Population Health Management in scheduling ICT meetings with contracted providers within assigned geographic area
- Identify gaps in network composition and services to assist the network contracting
- Understands, develops, tracks, monitors and reports on key program performance metrics, such as utilization, coding, and STARs/quality performance
New York, NY
Senior Provider Relations Representative
New York, NY
Stanton-DuBuque
New York, NY
Senior Provider Relations Representative
- Communicates effectively with physicians and their office staff as well as with internal partners
- Assures compliance with respective contracts. Researches, analyzes and resolves claims, benefits, issues and authorization inquiries within delegated authority
- Influences membership growth and retention through the provider offices
- Monitors provider database of current data relating to provider and physician information
- Ensures provider directories are accurate
- Investigates compliance issues, identifies root cause, trains provider office staff on correct procedures, and provides written report of findings and recommendations
- Meets on a regular basis in person or by telephone with assigned key provider groups to cultivate and strengthen relationships. Documents office visits and provider issues on shared drive log
present
Boston, MA
Healthcare Vision Senior Provider Relations Representative
Boston, MA
Graham, Koepp and Heaney
present
Boston, MA
Healthcare Vision Senior Provider Relations Representative
present
- Support and implement strategies relating to the development and management of a provider network
- Provide explanations and information to others on topics within area of expertise
- Prioritize and organize own work to meet deadlines
- Investigate non - standard requests and problems, with some assistance from others
- Involved in identifying and remediating operational short - falls and researching and remediating claims
- Use pertinent data and facts to identify and solve a range of problems
- Assists Provider Relations Managers with research to identify new providers for recruitment into Beacon Health Options Provider Network
Education
Education
Bachelor’s Degree in Business
Bachelor’s Degree in Business
Arizona State University
Bachelor’s Degree in Business
Skills
Skills
- Solid knowledge and understanding of managed care industry and various provider payment methodologies, including claims experience/knowledge of medical coding
- Ability to make good judgment conclusions based on data available with minimal supervision
- Excellent problem solving skills, good follow up abilities and willingness to be flexible and adaptable to changing priorities
- Ability to maintain productive work relationships with various providers, departments, and professionals at all levels
- Strong attention to detail
- Have a professional demeanor and good public relations abilities
- Basic skill level in Microsoft Word and Excel
- Strong comfort level speaking to physicians
- Very strong verbal and written communication skills
- Acting as a resource for providers on an ongoing basis to answer questions and resolved issues as they arise and act as a liaison between providers and other Beacon departments
10 Provider Relations Representative resume templates
Read our complete resume writing guides
1
Provider Relations Representative Resume Examples & Samples
- Orient and train providers regarding company operations
- Meet with key hospital, physician group, and community-based providers on a regular basis to identify problems and/or concerns; maintain relations with key provider contacts to ensure and support mutually beneficial relationships and ongoing collaboration
- Assist providers as necessary with problem resolution
- Work with internal staff to resolve provider issues with regard to billing, payments, denials, authorizations, and other interactions
- Assist in ongoing identification of providers needed for network completion or expansion
- Distribute and collect provider contracts; prepare contract/application packets for credentialing
- Support the Provider Relations ACD line (call line) and the Provider Relations email box
- Manage and/or support other projects and activities as assigned
- 3 plus years' experience working in a healthcare environment (preferably in the managed care industry) and experience working with managed care systems (claims processing, enrollment, etc.)
- Strong customer service and marketing skills
- Ability to work well with physicians, clinicians, practice and health system administrators, frontline provider staff and Senior Whole Health staff
- Bi-lingual in Mandarin or Cantonese
- Direct Provider Relations experience
2
Provider Relations Representative Resume Examples & Samples
- 3+ years of provider relations experience
- Solid knowledge and understanding of managed care industry and various provider payment methodologies, including claims experience/knowledge of medical coding
- Strong comfort level speaking to physicians
3
Provider Relations Representative Resume Examples & Samples
- Bachelor’s Degree in business or health-related field
- 2+ years of managed care, provider contracting or provider services experience
- Knowledge of healthcare terminology
- Familiarity with contracting language and fee negotiations
- Effective customer service skills
- Ability to maintain productive work relationships with various providers, departments, and professionals at all levels
- Demonstrated organizational skills, record keeping, and time management skills
- Able to work well independently, handle multiple projects and assignments, and follow through to completion $
- Basic skill level in Microsoft Word and Excel
4
Bilingual Provider Relations Representative Resume Examples & Samples
- Working knowledge of healthcare reimbursement methodologies
- 3+ years of experience working in a healthcare environment, preferably in the managed care industry
- 3+ years of experience working with managed care systems
- Bilingual, Chinese and English
- Strong Customer Service skills
- Excellent organizational, analytical, and follow-up skills
- Exceptional presentation skills
- Ability to work well with physicians, clinicians, practice and health system administrators, as well as frontline provider staff
- Comfortable working independently in a fast-paced environment
- Working knowledge of and experience with Medicare and Medicaid programs
5
Provider Relations Representative Resume Examples & Samples
- Responds to written and verbal provider inquiries relating to our bill review analysis. Analyzes problems using problem solving methodology skills to determine root cause; communicates and implements solutions
- Resolves issues successfully in a proactive and timely manner. Communicates outcome to client services department
- Provides proactive service for assigned clients including issue resolution, education and interpretation of state specific fee schedules, rules, regulations and guidelines
- Acts as primary liaison between provider and StrataCare
- Identifies training and system deficiencies and issues; reports to Manager
- Documents activities in monthly meetings log
- Provides the highest level of customer service to customers, whether these are current or prospective clients of the Company, vendors, staff, business partners or visitors
- Manages confidential client, financial and employee information with discretion and good judgment in accordance with department and Company guidelines
- Thorough knowledge of the State of California Labor Code and its rules and regulations
- Thorough working knowledge of Company products, department policies, procedures and generally accepted Provider Relations practices
- Thorough understanding of healthcare cost containment industry
- Experience in dealing with dated materials and strict time limits
- Ability to work independently, analyze business information and arrive at sound recommendations
- Effective interpersonal and customer service skills
6
Provider Relations Representative Resume Examples & Samples
- Travels frequently to physicians offices doing site visits, educating office staff, recruiting new offices, and resolving established problems
- Provides education to physicians and their office staff. This includes, but is not limited to coordinating orientation and education of providers, hospitals and the organizations insurance plan administration staff
- Identifies and resolves managed care issues concerning claims, contract interpretation, utilization management, eligibility and general operational issues
- Maintains all levels of communication with network providers, informing them of any operational, procedural, and contractual changes and updates
- Assists internal departments in resolving provider and member appeals pertaining to the organizations physician, hospital, and insurance plan contracts
- Assists manager with network development in various geographic regions within the organization, negotiates, implements and maintains managed care contracts with payers and providers
7
Provider Relations Representative Resume Examples & Samples
- 1+ year of experience in a Provider Relations, Customer Service or relevant position with demonstrated ability to perform the duties of the position is required
- Experience working in a Pharmacy, healthcare, provider or HMO/PPO environment is preferred
- Demonstrated customer service skills
- Microsoft Word is required
8
Provider Relations Representative Resume Examples & Samples
- Make outgoing calls to customers (providers/pharmacies/patients/carriers etc.) to confirm receipt of mailings and request action
- Review and analyze documentation and claim data to determine validity and proper action
- Update accounts receivable system with denial and group information
- Assist with high priority special projects that directly affect client relationships
9
Senior Provider Relations Representative Resume Examples & Samples
- Provide explanations and information to others on topics within area of expertise
- Ability to build and maintain strong business relationships
- Communicates effectively with physicians and their office staff as well as with internal partners
- 3+ years of experience in a claims, customer service or provider support role
- Ability to prioritize and meet deadlines from multi - staff members within the department
10
Provider Relations Representative Resume Examples & Samples
- Supporting those who direct and implement strategies
- Relating to the development and management of a provider network,
- Identify gaps in network composition and services to assist the network contracting
- Development staff in prioritizing contracting needs
- Involved in identifying and remediating operational short-falls
- Researching and remediating claims
- Apply basic knowledge of theories, practices and procedures
- Perform routine or structured work
- Respond to routine or standard requests
- Use existing procedures and facts to solve routine problems or conduct routine analyses
- Depend on others for instruction, guidance or direction
- 1+ years of experience in a Customer Service or provider support role
- 1+ years of managed care or medical insurance experience
- Experience with Microsoft Word and Excel
11
Provider Relations Representative Resume Examples & Samples
- 1+ year of experience in a Customer Service or provider support role
- 1+ year of managed care or medical insurance experience
- Experience with Microsoft Office, Word, and Excel
12
Provider Relations Representative Resume Examples & Samples
- Must be able to travel up to 75% within assigned territory
- Required a Bachelor's Degree in a related field
- Preferred experience working in a Pharmacy, healthcare, provider or HMO/PPO environment
- Intermediate demonstrated interpersonal/verbal communication skills
- Intermediate demonstrated written communication skills
- Intermediate demonstrated problem solving skills
- Intermediate demonstrated analytical skills
- Intermediate demonstrated customer service skills
- Intermediate demonstrated negotiation skills
- Intermediate ability to multi-task
- Required intermediate Microsoft Excel
- Required intermediate Microsoft Outlook
- Required intermediate Microsoft Word
13
Senior Provider Relations Representative Resume Examples & Samples
- Assures compliance with respective contracts. Researches, analyzes and resolves claims, benefits, issues and authorization inquiries within delegated authority
- Interprets Health Net's policies and procedures. Provides interpretation and clarification of benefits, eligibility, and access to care requirements. Escalates recurring or critical issues as appropriate to management. Acts as a conduit for resolution with Provider Network Management
- Assesses provider-training needs. Develops, implements, and conducts appropriate training programs and/or orientations for assigned provider staff
- Educates/trains providers and provider office staff about regulatory requirements including CMS/DMHC/DHCS
- Influences membership growth and retention through the provider offices
- Monitors provider database of current data relating to provider and physician information
- Investigates compliance issues, identifies root cause, trains provider office staff on correct procedures, and provides written report of findings and recommendations
- Meets on a regular basis in person or by telephone with assigned key provider groups to cultivate and strengthen relationships. Documents office visits and provider issues on shared drive log
- Supports the retention of providers by participating in meetings, conducting research, and supporting provider credentialing
- Minimum three years experience in provider relations, health plan operations or health care/medical office environment
- Any combination of academic education, professional training or work experience, which demonstrates the ability to perform the duties of the position
14
Provider Relations Representative Resume Examples & Samples
- Monitor and Triage Provider Relations Workflow queue
- Maintain and update any provider data bases (as deemed appropriate)
- Perform site visits of waiver and other providers, as appropriate
- Develop, Assist with delivery of provider education in the following areas related to the contract, specifically with the Waiver provide population
- Bachelor's degree or equivalent years of service
- Experience with network management
- Ability to build strong client relationships
- Strong organizational, multi-tasking and time-management skills
- Experience working in a fast changing environment
- Experience with rapidly adapting to process changes
- 2 + years’ experience in customer service, public relations, education or related field
- Personal Computer experience (Microsoft Office Suite)
- Proven ability to work independently and as a team member
- Good communication (written and oral) and interpersonal skills
- Proven organizational and time-management skills
15
Provider Relations Representative Resume Examples & Samples
- Provide tactical operations support to assigned groups, including contracting, data integrity, communications, and relationship management
- Create and deliver materials to educate providers and provider staff on contracts, policies and procedures, quality and service line initiatives, and financial performance
- Prepares and delivers presentations with providers, provider staff, and/or physician leadership during monthly operational meetings
- Understands, develops, tracks, monitors and reports on key program performance metrics, such as utilization, coding, and STARs/quality performance
- Perform root cause analyses and resolution related to provider concerns, grievances, claims and care delivery
- Assist in the STARS and clinical metrics data collection, and design plans for enhanced provider engagement in quality initiatives
- Prepare materials and participate in monthly financial review with senior leadership
- Partners with other internal departments, including but not limited to Health Services, Medical Economics, Sales, and Coding in order to develop solutions for strategic business needs
- Work closely with internal representative for needs and support
16
Provider Relations Representative Resume Examples & Samples
- Bachelor’s Degree (BA/BS in Business, Healthcare, Operations Management, Finance, or related field preferred)
- Demonstrated ability to effectively adapt to new situations and handle ambiguity
- Customer service experience with focus on meeting customer needs
- Demonstrated proficiency of interpersonal and communication skills
- Self-motivated and ability to operate independently
- Long term career goals in operations and/or management
- Requires at least 65-75% local travel to network providers
- Coverage area - Philadelphia, PA and surrounding counties OR Delaware, Maryland Suburban, DC area
17
Provider Relations Representative, Senior Resume Examples & Samples
- Handles more complex and higher volume providers
- Provides education, training and mentoring to newly hired or less experienced Provider Relations Representatives
- Assists management on special projects and/or initiatives
- Required 3+ years of experience in Provider Relations, Network Management, Hospital Contracting or related Provider Services position demonstrated ability to perform the level of duties of the position
- Required 1+ year of experience in Medicaid/Medicare
- Intermediate Demonstrated negotiation skills
- Demonstrated organizational skills
- Intermediate Knowledge of community, state and federal laws and resources
- Intermediate Other Ability to explain complicated financial terms and utilization data to physicians/staff
- Intermediate Other Ability to understand, interpret and communicate all types of provider and regulatory contracts
18
Provider Relations Representative Resume Examples & Samples
- Minimum of 3 years recent and related customer service experience with exposure to provider networks and benefit plans
- Experience with managed care policy and direction, provider reimbursement methodologies, and benefit plan design is highly desired
- Strong communication; written and verbal
- Strong Microsoft skills - Outlook, Excel, & Word required
19
Provider Relations Representative Resume Examples & Samples
- Required Intermediate Microsoft Excel is required
- Required Intermediate Microsoft Outlook is required
- Required Intermediate Microsoft Word is required *LI-RG1
20
Provider Relations Representative Resume Examples & Samples
- Strong Demonstrated Customer service experience with focus on face to face customer relations
- Excellent Demonstrated analytical and problem-solving capabilities
- Requires local travel to network providers (Winston - Salem)
- Bachelor’s Degree highly desirable
21
Affiliates Provider Relations Representative Resume Examples & Samples
- Travel to various affiliate clinics to conduct training, and provide daily operational trouble shooting
- Sufficiently document and maintain records relative to communications with assigned providers to ensure a mutual understanding of expectations
- Meets with assigned providers regularly and proactively identify education and performance improvement opportunities through these interactions and/or feedback from staff
- Seeks out provider information to support company initiatives and implementation strategies
- Manage high volume of provider inquiries and ensure consistent follow through on resolution of provider issues
- Minimum: 2 years progressively responsible work experience in healthcare, in a Provider Relations/Customer Service environmentwith demonstrated ability to perform the duties of the position
- Knowledge of Medicare Advantage (health plans)
- Previous healthcare provider relations experience
- Working knowledge of provider offices and relationships with health plans
- Ability to effectively present and educate office staff and physicians
- Demonstrated competence in Microsoft Office, including Outlook, Word, Excel & Power Point
- Ability to establish rapport and interact well with staff at all levels, and maintain a professional image and attitude
- Ability to communicate effectively and professionally and establish and maintain effective working relationships with physicians, senior management, staff, and vendors
- Ability to work independently with general guidance
- Detail oriented and ability to handle multiple tasks with excellent organizational skills and workplace flexibility
- Resolve provider inquiries or requests in a timely manner
- Must be able to present a positive, professional and pleasant image while interacting with various personalities
22
Healthcare Provider Relations Representative Maine Resume Examples & Samples
- Acts as primary liaison with the provider network
- Work collaboratively with Network Operations, Network Contracting, Network Medical Management, Care Management, Sales, Policy, Reimbursement, Member Services and other departments for issue resolution
- Communicates to internal constituents regarding critical issues that impact the providers’ overall performance and satisfaction. Consultant is skilled at determining when issues are not being effectively resolved and appropriately elevates issues to management as needed
23
Healthcare Provider Relations Representative Resume Examples & Samples
- Addresses escalated issues and problems affecting provider reimbursements. Must identify, and negotiate mutually beneficial resolutions to escalated issues and problems
- Coordinate and present to large/small groups, societies, associations and industry groups to represent HPHC
- Demonstrates a thorough understanding of network providers’ contractual and reimbursement arrangements. Is conversant with contractual terms of all provider types (i.e., physician, hospital and ancillary) in the HPHC provider network
- Clear understanding of claim submission and processing
24
Provider Relations Representative Resume Examples & Samples
- Strong analytical and written/oral communication skills
- Multi-functional experiences; Required
- Multi-functional experience (ability to multitask); Required
- 1-2 year or more Medical Claim Experience; Required
- Contracting; Preference
- 1-2 years or more Customer Service experience; Required
25
Provider Relations Representative Resume Examples & Samples
- Performs research and problem resolution on issues related to provider complaints, claims reported to have been processed incorrectly, coordinating credentialing paperwork, provider communications, or verification of information as requested
- Provides assistance in compilation and mailing of provider recruitment mailings, general information, and educational materials to network practitioners as required
- Works closely with regional Network Operations team to ensure seamless customer service to providers
- Answers practitioner/facility recruitment questions regarding Beacon Health Options policies and procedures
- Assists Provider Relations Managers with research to identify new providers for recruitment into Beacon Health Options Provider Network
- Microsoft Products – Outlook, Word, PowerPoint and Project
- Demonstrated ability to interact with mental health, substance abuse and employee assistance program providers
- Excellent problem solving skills, good follow up abilities and willingness to be flexible and adaptable to changing priorities
26
Provider Relations Representative Resume Examples & Samples
- Serve as a liaison between the network and the health plan
- Onboard new physicians as well continue education with contracted providers to ensure providers remain in compliance with regulatory and plan guidelines
- Heavy emphasis on site visits
- Assist with claims resolution
- Provider Portal training
- Ensure provider demographics are accurate
- Assist with incoming provider telephone line
- Familiar with MS Word, Excel, and Access
- Ability to prioritize multiple tasks and perform complex functions with minimal to no supervision
- Ability to work self-directed
- Experience with Facets and Macess is
- Experience with Nevada health insurance
27
Affiliate Provider Relations Representative Resume Examples & Samples
- Enhance and maintain positive provider relationships to ensure company vision is met
- Serve as a liaison to the provider community in resolving complex problems
- Responsible for understanding the complexity of assigned clinics, and how provider sites and administrative staff are interrelated
- Supports the development, implementation, and ongoing maintenance of company initiatives and operations
- Ensures professional growth through management and self-directed learning opportunities
- Support team members and provide support to other clinics as needed
- Other duties as assigned
- Basis Medical office terminology
- Basis knowledge of referrals, encounters, claims,
- Understanding of billing practices and reimbursement methods
- Excellent project management skills along with excellent written, oral and presentation skills
- Ability to travel locally
- Bilingual (English/Spanish) a plus
28
Hospital Outreach Phycisian & Provider Relations Representative Resume Examples & Samples
- Most desired experience will include hospital sales in the Market. Minimum requirements include five (3) years of progressive healthcare sales experience in pharmaceutical or medical devices. Comparable experience may be considered
- Prefers a minimum of a Bachelor's Degree in business, healthcare administration, public health administration or related field from an accredited college or university; Master's degree in Health Administration, Business or Economics preferred
- Requires the ability to travel by automobile in the service area on a regular basis - some overnights may be required
29
Provider Relations Representative Resume Examples & Samples
- Provides feedback to ACO leadership to ensure ACO initiatives and optimize physician satisfaction and engagement
- Generates and communicates reports developed by the ACO analytics team on performance related to overall outcomes and quality, utilization, total cost of care, population health, and care management and coordination to ACO practices
- Reviews health plan incentive programs and educates and provides information to ACO members
- Knows, understands, incorporates, and demonstrates the mission, vision, and values of CHE Trinity Health in behaviors, practices, and decisions
- Has a working understanding and also values the vision and strategies of Population Health
- Leads efforts to support partnering to become more accountable for better care, better experiences and reduced healthcare costs for the populations the ACO serves
- Works with ACO leadership on organizational performance initiatives and direction
- Serves as the liaison between ACO leadership and ACO participant practices
- Identifies and prioritizes gaps in care and assists with performance improvement opportunities
- Supports organizational goals related to the quality improvement and performance management initiatives
- Tracks, trends and reports results of key clinical and service indicators established for quality programs
- Analyzes and reports network performance on quality, utilization and cost measures
- Monitors and reports network performance trends
- Communicates updates to physicians/practices related to all ACO payer programs
- Attends ACO Board of Directors and Quality Committee meetings
- Attends external committee meetings as they relate to ACO population management
- Cultivates positive relationships with all ACO participants
- Maintains a working knowledge of applicable Federal, State, and local laws and regulations, CHE Trinity Health’s Organizational Integrity Program, Standards of Conduct, as well as other policies and procedures in order to ensure adherence in a manner that reflects honest, ethical, and professional behavior
- Comprehensive knowledge and understanding of care management, disease management and population health as normally obtained through completion of a Bachelor's degree in a healthcare related field or information technology and/or demonstrated experience in a related area and/or a minimum of five (5) years of ambulatory practice administration or population health experience
- Two (2) to five (5) years of experience in data analysis and reporting, clinical quality measurement, and support for management decision making; experience with population health metrics preferred
- Experience and demonstrated successful leadership of disease management and/or population health programs. Thorough knowledge of, and experience with, principles of practice operational workflows
- Knowledge and understanding of claims layout and data sets to ensure accurate reporting
- Proficiency with clinical information systems supporting population health management
- Advanced knowledge of Microsoft Office Products required
- Knowledge of HEDIS and NCQA specifications
- Strategic and innovative thinker with proven ability to communicate a vision and drive results related to population health metrics
- Ability to problem solve and execute initiatives
- Strong data collection, manipulation and analysis skills including ability to formulate conclusions and identify trends from data in a logical and systematic manner
- Excellent verbal and written communication and interpersonal skills
- Ability to communicate a vision and drive results related to population health metrics
- Demonstrated management and organizational skills
- Must possess a personal presence that is characterized by a sense of honesty, integrity and caring with the ability to inspire and motivate others to promote the philosophy, mission, vision, goals and Values of CHE Trinity Health
30
Provider Relations Representative Resume Examples & Samples
- Develop a strong working relationship with providers in an assigned geographical area so that office staff and provider issues can be raised proactively with ConnectiCare; this may include regular visits with tier II and III providers
- Delivers the provider message from CCI to the provider network as needed. May develop materials to leave with providers
- Participates in PHO, Hospital or Provider Committees to review issues concerning reimbursement, policy or CCI standards. Brings issues presented by the provider community back to the plan and facilitates resolution to the issue
- Acts as an information resource to the call center when needed to identify and problem solve issues
- Identifies and makes recommendations on issues and concerns related to provider relationships
- Recognizes and refers policy and procedure problems to management based on interaction with physicians
- Identifies trends/issues with providers and develops educational programs when appropriate
- Acts as an internal resource for Network Operations and ConnectiCare for ensuring provider demographic data is accurate and produces desired results in terms of claim payments and provider satisfaction. Assists other departments in resolving complex problems with providers and communicates the resolution by phone and/or letter
- Performs other related duties and projects as assigned
- Bachelor's Degree required, or equivalent combination of education and experience
- At least 3 years of previous experience in a health care organization dealing with providers required, preferably in a managed care environment
- Understanding of claims payment and various reimbursement methodologies
- Presentation and teaching skills required
- Excellent oral and written communication interpersonal skills required
- Demonstrated analytical abilities
- Initiative and leadership abilities
- Must be able to analyze contracts and describe their intent to providers
- Must be able to understand insurance products and describe them to providers
- Previous system user experience in a highly automated environment required
- Must demonstrate the ability to prioritize high volume tasks successfully
31
Provider Relations Representative Resume Examples & Samples
- Resolve administrative problems affecting network providers, patients, and plans within contracted guidelines for which the network is responsible
- Process contracts and contract edits in multiple provider databases while ensuring the accuracy of the data
- Process dental and vision requests
- Coordinate questions received via website
- Prepare provider directories
- Complete 1099 Projects/Returns
- Work with other departments, groups, members, and/or agents to resolve provider related issues s
- Assist in state reporting and filings
32
Provider Relations Representative Resume Examples & Samples
- Coordinate and conduct orientations and training for newly contracted physicians and established providers to ensure the provider understands their roles and responsibilities
- Maintain a working knowledge of the Medicaid programs and procedures, and the ability to communicate information to the external provider community and internal customers
- Meet all contractual obligations while establishing positive interpersonal relations among all individuals involved within the program
- Assess user needs using assessment tools to determine effectiveness of training programs
- Evaluate needs and develop new training materials and or revises current material to ensure business unit, external audiences and or group training needs are met
- Evaluate training methodology and provide recommendations for appropriate solutions when necessary
- Interact with functional organizations to develop specifications for content of courses
- Conduct follow up to evaluate determine applicability of course materials
- Conduct face to face meetings with Providers and the Regional Advisory Council
- Minimum of 3 years of work experience in communications, teaching, or public relations
- Minimum of 1 year of healthcare experience, project support and/or management
33
Provider Relations Representative MSO Resume Examples & Samples
- Successful experience in administrative functions and a working knowledge of health care administration practices, managed care systems, customer service and provider relations
- Effective communication and computer skills are critical as are good judgment and decision-making skills
- Strong attention to detail, interpersonal relations and team building skills are a requirement for internal and external purposes
- Bachelor’s degree in health care administration, business administration or related area is preferred
- Work history emphasis within a medical group, independent physician association, management services organization or physician hospital organization
34
Provider Relations Representative Resume Examples & Samples
- Read, abide by, and demonstrate an understanding of all policies, procedures, contract requirements, and laws that apply to job. Seek clarification from supervisor if ever unclear about a policy, rule, contract provision, or legal obligation
- Adhere to HIPAA laws at all times; notify Privacy Officer immediately upon learning of a real or potential breach of protected health information
- Complete initial orientation and annual mandatory educational requirements
- Participate in quality activities to include: reporting and following up on grievances and complaints, participating in quality/performance improvement projects and accreditation activities
- Microsoft Windows applications
- Knowledge of Medicaid preferred
- Ability to plan and organize
- Strong customer service skills and techniques
- Strong presentation and oral and written communication skills
35
Provider Relations Representative Resume Examples & Samples
- Assure that assigned providers have current copies of all relevant educational materials, including the billing handbook and provider manual; is responsible for accurate interpretation of materials to providers in a consistent fashion and for identifying and proposing solutions to problems as they arise
- Assure that providers meet the clinical needs of enrolled consumers while continuing to comply with service delivery standards
- Balance time and effort spent on external provider servicing with in-office responsibilities
- Coordinate service schedule with other Service Reps to ensure adequate and consistent phone coverage
- Develop and implement an Action Plan in response to each provider service call
- Establish excellent working relationships with a defined panel of providers
- Implement use of quality indicators for use within the network, including work with providers as necessary to assure full understanding and compliance
- Manage supplemental service enrollment process for his/her designated panel of providers
- Meet or exceed specified goals for the number of provider service meetings on a quarterly basis
- Participate in development and delivery of provider orientation and for follow-up as needed with assigned group
- Responsive to deadlines; complete assignments within deadlines at least 95% of the time
- Share responsibilities with other department personnel for answering the provider line
- Understand and communicates the details of the authorization process and Community Care's procedures for delivering the authorizations to providers
- Work as member of the Provider Relations staff, ensure that corrective action plans are implemented and result in complete problem resolution
- Work with colleagues on development of provider newsletter and other educational materials
- Work with the Director, Provider Relations and other staff as appropriate to develop the provider manuals and handbooks; this process will involve provider input as well as advice from appropriately designated advisory groups
- B.A .or B.S. degree in a healthcare, human services or related field
- 2 years of experience working in a complex organizational environment
- 2 years of experience in healthcare or managed care environment
- Experience as a provider of behavioral health services and/or knowledge of behavioral health provider system strongly preferred
- Must clearly and consistently articulate standards of care and specifics of the various provider agreements
- Independent problem-solving skills, including the ability to address issues in a timely and accurate manner
- Knowledge of public and private delivery systems in behavioral health care
36
Provider Relations Representative Resume Examples & Samples
- Educating providers and office staff on contracts, policies, and procedures
- Managing monthly face to face provider visits and calendar of events
- Prepare for and participate in meetings with providers, provider staff, and/or physician leadership
- Manage joint operations committee (JOC) meetings. This includes: formulating meeting agenda and recording minutes from meeting
- Work with Population Health Management in scheduling ICT meetings with contracted providers within assigned geographic area
- Planning, creating, and delivering presentations
- Partners with other internal departments, including but not limited to Health Services, Medical Economics, Sales and Coding in order to develop solutions for strategic business needs
- Participate in monthly financial review with senior management
37
Provider Relations Representative Resume Examples & Samples
- Conduct on-site visits to provide orientation, continuous training and education to the provider network. Partner with the health care provider network to encourage their support of company initiatives as well as compliance with policies and procedures
- Monitor, analyze and develop strategies for improving network participation and performance. Recruit additional providers to enhance the company’s ability to promote a network to current and potential customers. Deliver efficient communications between providers and the corporation, ensuring providers utilize various electronic means of communication
- Fulfills a liaison role with Operations and Support areas to ensure the appropriate development and execution of initiatives, communication needs, and issue resolution
- Communicates and maintains effective working relationships both internally (team members, management, and other key areas with whom we work closely) and externally (providers, provider associations, vendors) keeping management informed on related healthcare industry issues/topics
- May be a team member for corporate projects impacting providers ensuring team and provider communication is appropriate, provider impacts are considered, and appropriate tasks are executed by team members
- May provide strategic and operational input for network development and servicing to ensure members have access to quality, cost effective care and that the plan appropriately and timely responds to the customers’ needs and efficient/effective operations of the department are maintained to meet corporate initiatives
- 3-5 years of provider relations experience
- 1-3 years of Project Management and/or Business Analyst experience
- 3 years of management or leadership experience
- Strong interpersonal organizational and analytical skills and management skills and the ability to perform under pressure within rigid time constraints, without the loss of efficiency, quality and professionalism as demonstrated by previous positions held
- Willingness and agreement to continue educational course work in direct relation to the position and travel for additional training or business purposes as necessary
- Demonstrated ability to analyze situations and data to identify issues, determine points of relevance and proper course of actions
- Superior communication (written and oral), teamwork, organizational and leadership skills as demonstrated through previous performance, testing and/or academic background
- Ability to identify, establish and meet corporate goals and objectives
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Senior Provider Relations Representative Resume Examples & Samples
- Investigate non-standard requests and problems, with some assistance from others
- 1+ years experience in a claims, customer service or provider support role
- Basic level of proficiency with MS Excel and Word
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Provider Relations Representative Resume Examples & Samples
- Conducts regular provider visits to educate providers and office staff on topics including, but not limited to: health plan operations/policies and procedures, preventative and quality outcome metrics, risk adjustment, etc
- Conducts root cause analysis and resolution of provider concerns
- Participates in monthly financial review with senior management
- Prepares for and participates in meetings with providers, provider staff, and/or physician leadership, and plans, creates and delivers presentations
- May provide guidance to others in the department
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Provider Relations Representative Resume Examples & Samples
- A Bachelor's Degree in a related field required
- 1+ year of experience in a Provider Relations, Customer Service or relevant position with demonstrated ability to perform the duties of the position required
- Experience working in a Pharmacy, healthcare, provider or HMO/PPO environment preferred
- Intermediate - Demonstrated written communication skills
- Intermediate - Demonstrated problem solving skills
- Intermediate - Demonstrated analytical skills
- Intermediate - Demonstrated customer service skills
- Intermediate - Ability to multi-task
- Intermediate proficiency in Microsoft Outlook, Word, and Excel
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Provider Relations Representative, Senior Resume Examples & Samples
- 3+ years of experience in Provider Relations, Network Management, Hospital Contracting or related Provider Services position demonstrated ability to perform the level of duties of the position required
- 1+ year of experience in Medicaid/Medicare required
- Intermediate - Demonstrated negotiation skills
- Intermediate - Demonstrated organizational skills
- Intermediate - Ability to work independently
- Intermediate - Ability to explain complicated financial terms and utilization data to physicians/staff
- Intermediate - Ability to understand, interpret and communicate all types of provider and regulatory contracts
- Intermediate proficiency in Microsoft Outlook, Word, and Excel required
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Provider Relations Representative, Dental Resume Examples & Samples
- Engage with provider on continuous servicing and resolution of issues
- Assist with provider education
- Assist with completion and maintenance of provider documentation
- Responsible for timely resolution of ISET and Scion tickets
- Provides additional provider support when recruiter is in the field recruiting
- Engages providers to collect missing re-credentialing documentation
- 1+ year of managed care and / or clinical dental experience
- 1+ year of experience in customer service or provider support role
- Experience with Medicare regulations
- Proficiency in claims and issue resolution
- Strong interpersonal and oral communication skills including telephone etiquette
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Provider Relations Representative Resume Examples & Samples
- Identifies and resolves provider issues by researching causes and working with Beacon’s clinical, operations and IT teams
- Performs active outreach to ensure compliance with access and availability
- Other duties and projects as assigned in line with Department and company needs
- Very strong verbal and written communication skills. Previous data entry required
- Must be detail oriented and able to work independently in a fast changing environment
- Strong understanding of managed care and healthcare operations
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Senior Provider Relations Representative Resume Examples & Samples
- Fosters a close working relationship with assigned physician offices including communicating with provider office regarding member/provider issues. Independently researches and resolves concerns/issues for provider offices and provides accurate and timely answers. Monitors and tracks service issues and inquiries for identification and trending of education opportunities/programs to improve overall provider service and satisfaction (25%)
- Manages monthly provider visits and calendar of in-services to new and established physician offices. Interprets health plan policies and procedures and develops training tools and guidelines to train provider network to ensure compliance. Develops training programs on Point of Care Tools i.e. Ascender and Referral Management System and conducts training. Updates Provider Manual as necessary to ensure manual reflects most current information for network providers. (25%)
- Responsible for developing SJHH Network Communications and collaborating with Provider Network Operations to effectively distribute notifications. (15%)
- Collaborates with Network Development to identify providers within all specialties for recruitment. (5%)
- Conducts access survey, analyzes data and develops corrective action plans as required. Conducts necessary training as needed to ensure compliance. (10%)
- Conducts physician office meetings and other network trainings by planning, creating, and delivering presentations (10%)
- Coordinates and attends health fairs, senior events including ABCs of Medicare Meetings, employer events and other various enrollment functions to promote networks. (5%)
- Acts as a liaison with various SJHH Departments, physician offices and health plans to resolve provider issues and facilitate notifications (5%)
- Keep informed of current health/managed care information
- Training of new Provider Relations staff on Provider Relations policies and procedures
- Requires three (3) plus years’ experience as a Provider Relations Representative working with physicians in a Managed Care/IPA, Medical Group, Health Plan or MSO environment
- Advanced knowledge of managed care principles and methodologies
- Basic computer skills including Windows, Microsoft Office Word, Outlook, and Excel
- Strong interpersonal and organizational skills to achieve desired goals and to interact effectively with management and non-management staff and physician groups
- Attention to detail and follow-up skills required
- Must be able to maintain a positive attitude under changing conditions
- Ability to seek out available resources to resolve problems
- Must be able to make independent decisions
- Must have a professional and mature demeanor
- Must be able to work in a fast-paced department while handling multiple tasks, working with interruptions, and dealing effectively with confidential information
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Provider Relations Representative Resume Examples & Samples
- Maintain network participation by providing support to dentists and dental office managers to improve their understanding of all available benefit programs
- Educate providers by instructing and advising of the comprehensive policies and procedures involving all phases of the corporation's benefits and contracts through office visits and communication over the phone and email
- Promote dentist adoption of technology solutions by promoting Web applications and increasing the volume of electronic claims
- Recruit non participating providers to join our networks
- Negotiate special deals to maintain compliance and increase access in weak networks
- Seek continuous improvements by recommending changes in internal methods and procedures to Quality Assurance process
- Facilitate Oral Health presentations to various educational institutions and organizations
- Assist provider offices in filing their claims electronically
- Serve as a liaison with dental offices by answering remittance, payment, benefit, claims, and eligibility questions when necessary
- Follow up with all termination letters submitted
- Represent clients and company at health fairs, audits, dental summits, etc throughout your designated market
- Maintain and submit all required reports
- Assist in resolving elevated complaints and issues for clients, members and providers
- Obtain letters of recommendation from providers
- Develop complete understanding of the Office Reference Manuals
- Develop and continually improve personalized presentations of company benefit programs
- Recruit participating and non-participating providers to higher levels of participation
- Provide recommended solutions to market related issues
- Organize and present information to providers and their staff by speaking before various provider organizations and representing the corporation in dental related activities
- Assist in problem resolution by identifying improvement opportunities, evaluating feasibility of programs and presenting recommendations when appropriate
- Develop and implement approaches by working with dentists and their office staff to improve the quality of information exchanged between the company and dental offices
- Resolve difficult claims issues in a timely manner by working with the appropriate internal resources to research and resolve such issues
- Increase access for members by strengthening and expanding existing network
- Help to maintain a secondary network
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Provider Relations Representative Resume Examples & Samples
- Proven problem-solving skills
- Own transportation for office and site visits (10% - 50% travel required). Valid driver’s license required
- Problem solving and training experience
- Ability to make good judgment conclusions based on data available with minimal supervision
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Healthcare Vision Senior Provider Relations Representative Resume Examples & Samples
- Use pertinent data and facts to identify and solve a range of problems
- Support and implement strategies relating to the development and management of a provider network
- Identify gaps in network composition and services to assist the network contracting and development staff in prioritizing contracting needs
- Involved in identifying and remediating operational short - falls and researching and remediating claims
- 2+ years of managed care or medical insurance experience
- Moderate level of proficiency with MS Excel and Word
- Proficiency working with SharePoint, Salesforce
- Good organizational and planning skills
- Strong interpersonal and oral communication skills, including telephone etiquette
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Provider Relations Representative Resume Examples & Samples
- Coordinate with Contract Manager and Director on Key Network Implementation
- Answering provider questions about Beacon, its contracts, policies and procedures
- Maintain a collaborative relationship with the operations, business personnel and provider community to incorporate process-related information into the training curriculum
- Remain current on regulatory and company policy that impacts the provider network and related issues
- Solid technical writing skills with a demonstrable ability to translate technical jargon and information into business-friendly language
- Manage multiple, simultaneous, and complex projects
- Engaging providers in Beacon’s quality improvement activities
- Acting as a resource for providers on an ongoing basis to answer questions and resolved issues as they arise and act as a liaison between providers and other Beacon departments
- Conduct provider site visits and other audits to ensure provider compliance with Beacon policies and NCQA accreditation standards
- Negotiate fee for service rate changes and contract terms with network providers
- Identifying and soliciting providers based on network need for new and existing business
- Securing completed contracts and credentialing materials from providers who have been invited to join the network
- Provide general support to all Network development activities
- Collaborate with other departments to address and resolve operational issues as related to negotiated contract language
- Other duties as assigned and specified by supervisor in line with Department and company needs
- Very strong verbal and written communication skills
- Strong understanding of managed care and health care operations.Behavioral health experience preferred
- Must be well organized. Requires excellent communication and writing skills
- Have a professional demeanor and good public relations abilities
- Advanced level of PC skills required in Word and Excel
