Provider Relations Resume Samples

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L Feeney

Lindsey

Feeney

12412 Maryse Springs

Houston

+1 (555) 466 3889

12412 Maryse Springs

Houston

Phone

p +1 (555) 466 3889

Experience Experience

Boston, MA

Provider Relations Coordinator

Boston, MA

Moen-Hane

Boston, MA

Provider Relations Coordinator

Supporting all contracting solicitation and enrollment efforts. Working closely with Provider Contracting and Retail Network Operations
Partner with practice staff and act as a single point of contact to field and resolve physician/practice questions/issues regarding fee schedules, referral simplification, patient population confirmations and other ad hoc network projects by coordinating across Steward teams to ensure task completion and/or resolution
In conjunction with provider enrollment, help physicians maintain current contact and practice information in the Steward provider database that feeds the web-based tools used by patients to contact and select Steward providers
Monitor production in assigned territory and work with key stakeholders to develop and maintain strategies that address deficiencies
Ensure effective communication with other teams to assure Provider Relations issues are managed quickly and efficiently
Provide quality assistance to HouseCalls Practitioner field by quickly and efficiently addressing practitioner concerns
Provide practices with both requested and network distributed reports

Los Angeles, CA

Provider Relations Manager

Los Angeles, CA

Rice-Pfannerstill

Los Angeles, CA

Provider Relations Manager

Progressive levels of responsibility related to claims processing
Comprehensive knowledge of all Microsoft Office applications, including Word, Project and Visio
Supports SNP implementation locally; collaborating with key implementation stakeholders
Manage the various accounts and internal/external relationships associated with the SNPs; develop new and maintain existing physician relationships with Nephrologists and other providers participating in VillageHealth Government programs
Develop and maintain relationships with health plan partners to pull all non-clinical levers to improve plan and product performance
Deliver executive level presentations to key stakeholders inside and outside of the DaVita Healthcare partners organization
Develop knowledge of competitive products and external factors in each market

present

Boston, MA

Provider Relations Specialist

Boston, MA

Kirlin, Christiansen and Volkman

present

Boston, MA

Provider Relations Specialist

present

Assist Provider Relations Manager in developing training materials
Assists and cooperates with co-workers, supervisor and management
Resolve administrative problems affecting network providers, patients, and plans within contracted guidelines for which the network is responsible
Assist with the development and monitoring of provider contracts
Provides timely assistance to DPHO providers on all other matters related to DPHO physician participation in DPHO MCO contracts
Proactively establishes and maintains positive working relationships with MCO executives, DPHO physicians, and DPHO practice managers
Identifies and establishes relationships with key providers involved in delivering an effective care delivery model to ESRD patients

Education Education

Bachelor’s Degree in Healthcare Related Field Preferred

Michigan State University

Bachelor’s Degree in Healthcare Related Field Preferred

Skills Skills

Knowledge of accountable care organizations care desired
Knowledge of managed care and integrated delivery networks
Conducts oneself professionally and courteously during interactions with others
Knowledge of general office machines and telephone system
Ability and willingness to work cooperatively with others
Promotes professionalism in appearance, respect for others, positive attitude, and confidentiality
Important notification to applicants as of Nov. 20, 2014: Effective Jan. 1, 2015, Centura Health will no longer hire tobacco users in Colorado and Kansas. The change to our policy does not apply to associates hired on or before Dec. 31, 2014. Centura Health is an Equal Opportunity Employer, M/F/D/V
Demonstrated ability to work independently and as a team
Good understanding of HMO systems provider reimbursement mechanisms
Knowledge of CPT-4 and ICD-9 coding systems

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Provider Relations Consultant Resume Examples & Samples

Bachelor’s Degree in Business or a related field
Extensive knowledge of multiple types of Current Procedural Terminology and Healthcare Common Procedure coding systems
Comprehensive knowledge of Microsoft Word, Excel and Access
Master’s Degree in Business, Finance or related fields

Provider Relations Market Leader Resume Examples & Samples

Proven planning, preparation and presenting skills, with established knowledge of reimbursement and bonus methodologies
Demonstrated ability to manage multiple projects and meet deadlines
Comprehensive knowledge of all Microsoft Office applications
Ability to travel ~25% as needed

Provider Relations Resume Examples & Samples

Demonstrated consultation and presentation skills
Progressive experience working in a healthcare setting
Knowledge of CMS processes and procedures
Comprehensive knowledge of Microsoft Word, Excel and PowerPoint
Reliable transportation and ability to travel locally
Ability to travel overnight
AAPC and/or AHIMA Coding certification
Knowledge of HEDIS & STARS initiatives
Experience working with Risk Adjustment Factors and/or Healthcare coding practices

Provider Relations Consultant NY City Resume Examples & Samples

Facilitates the strategic alignment of the providers, processes, and technology responsible for delivering Humana's signature consumer-oriented, quality-driven service
Bachelor’s Degree in Business, Finance or a related field; or a minimum of 2 years’ relevant business experience
Proficiency in analyzing, understanding and communicating financial trends
Knowledge of Microsoft Office applications
Medical claims experience

Provider Relations Consultant Resume Examples & Samples

Prior health solutions system experience in the areas of provider contracting, provider operations or related areas
Prior experience in a fast paced insurance or health care setting
Computer literate (MS Word, Power Point, Excel). Proven analytical skills, spreadsheet modeling and database development
Ability to travel 50%, including overnight travel
Excellent communication skills, both oral and written
Medicare industry experience; knowledge of Medicare Advantage, MRA, Quality, etc.
Graduate degree
Knowledge of Humana’s internal policies, procedures and systems

Provider Relations Field Manager Resume Examples & Samples

Bachelor’s Degree or equivalent job experience
Minimum five years in Medicaid or other healthcare related field
Three years leadership experience preferred with one year of management experience
Two years of claims examination and/or billing experience
Problem solve through analysis and ongoing feedback

Provider Relations Consultant Resume Examples & Samples

Functions as the single point-of-contact for all on-going contractual and service issues as needed by providers and develop and implement solutions that are beneficial to providers, Humana members, and the business-at-large
Educate providers about Humana’s ever-expanding portfolio of products and services, ensuring continually updated knowledge about the company’s offerings
Analyze data for cost reduction initiatives, guaranteeing profitable and efficient business relationships
Previous experience in provider contracting/provider relations

Provider Relations Specialist Resume Examples & Samples

Regularly communicates with the Care Management team on Provider Relations updates and issues
Evaluates member service needs reports to ensure that there are sufficient providers contracted to meet member care needs
Negotiates and maintains contractual relationships with vendors in areas of service needs
Schedules and organizes outreach presentations and serves as educator/liaison with providers to ensure providers are current on AEC programs, policies & procedures, billing practices, accessibility standards and contracted service requirements
Attends trade organization events, conferences and business networking meetings on a regular basis to market AEC products and programs
Consistently meets established productivity
Valid Driver's License and current auto insurance
ACHA Level II background clearance
This role is considered patient facing and is part of Humana’s Tuberculosis (TB) screening program. If selected for this role, you will be required to be screened for TB
Three years healthcare industry experience working in Provider Relations
Knowledge of Long Term Care Manage Care Plan
Bilingual a plus

Provider Relations Consultant Resume Examples & Samples

Bachelors degree in health- or business-related field
2-4 yrs in successful experience in completing efficient health-related research, with associated analysis and conclusions
Excellent PC skills (including MS Word, Excel and Access) required
Excellent communication skills, written and verbal
Project management experience desirable

Provider Relations Consultant North Carolina Resume Examples & Samples

Humana is seeking an individual to focus on servicing Humana's provider community
Educate providers about Humana's products and services
Receive, document and resolve provider inquiries by using established best practices
Coordinate and facilitate regularly scheduled provider meetings to discuss operational service and issue resolution strategies
Collaborate with internal partners to achieve market and enterprise goals
Prior experience in health care, managed care health plan or related setting
Strong relationship building skills, preferably in a provider relations/network environment
Comprehensive knowledge of Microsoft Office Suite
Excellent verbal & written communication skills with demonstrated presentation skills
Demonstrated organizational skills and ability to manage multiple priorities
Valid NC Driver License
Ability to travel within the state of North Carolina to include occasional overnight stays with no restrictions
Bachelor's Degree in Business, Finance or related fields
Knowledge of CPT coding systems, Medicare claim processing and regulations

Provider Relations Assistant Resume Examples & Samples

Ability to meet production goals without compromising product quality and integrity
10 key skills by touch and solid typing skills
Competency to utilize Company software and proficiency in Microsoft software applications and a willingness to learn new systems as necessary
Ability to work overtime as needed
The incumbent must be able to perform this job safely, without endangering the health or safety of him/herself or others

Provider Relations Director Resume Examples & Samples

7+ years of experience in Contract Negotiations, Network Development, Health Care Management, or Managed Care and/or Provider Relations; 5+ years of Supervisory experience
Bachelor's Degree in Health Care Administration, Business Management or an equivalent combination of education and related work experience in Managed Care or Health Care
Microsoft Office/Suite proficient (Word, Excel, and Access)

Provider Relations Market Leader Resume Examples & Samples

Experience working directly with physicians and an understanding of how physician groups operate
Proven ability to work consultatively with physicians using data to support changes in providing care and operational processes
Experience partnering with senior leadership on strategic initiatives
Risk sharing/value based reimbursement knowledge
Medicare Advantage knowledge
Demonstrated leadership ability and proven ability to lead through influence
Comprehensive knowledge of all Microsoft Office applications with a high level of proficiency with Excel
Ability to travel locally 50%-75% during the day
Flexibility with schedule
MSO and/or ACO experience strongly desired
Provider Contracting/Network Management knowledge

Provider Relations Field Representative Resume Examples & Samples

Applies understanding of the goals and objectives of the Medicaid Administrative Services Program and work within area of responsibility to ensure success
Coordinates resources to ensure excellent customer service; works collaboratively with Provider Relations management team to develop and implement strategic initiatives
Assists in preparation and updating of provider publications
Assists Department staff with public presentations, symposiums, and workgroups
Builds and maintains relationships with external stakeholders
Conducts formal training seminars and informal onsite assistance at provider offices
Contacts providers with identified billing issues to offer onsite service/visit
Coordinates/conducts orientations and training for newly enrolled providers and established providers to ensure they understand their roles and responsibilities, billing procedures, and program policies
Designs and develops workshops, in-service sessions, and conference materials
Develops education materials to include articles for bulletins, flyers, and any necessary correspondence to assist in educating providers on Medicaid issues
Maintains consistent communications with providers, including communication of policy changes/updates
Works closely with service center departments to identify and address provider education issues through office visits, workshops or other educational venues
Maintains documentation of provider visits, provider communications (verbal and written), and any necessary follow-up activities
Maintains schedule of regular provider office visits for goodwill and problem-solving efforts
Maintains working knowledge of the Medicaid Administrative Services Project Program policies and procedures and communicate information to external (provider community) and internal stakeholders
Participates in local medical community organizations
Promotes and demonstrates electronic claims transmission software to encourage provider participation
Represents Xerox and the Medicaid Program throughout the State and at professional association meetings
Researches and resolves provider inquiries and claims processing issues
Understands and applies the project management methodology to ensure efficient on-time delivery and high-quality results
Understands and applies the MMIS Quality Assurance practices in fulfilling all day-to-day job responsibilities
Requires driving to provider offices, workshops and provider association meetings
Bachelor’s degree preferred or one to two years related experience in the healthcare field, preferably Medicaid experience
Must live in the primary territory location or in a contiguous county which representative will serve
Current driver’s license required
Experience in conducting public speaking events/training

Centralized Provider Relations Network Specialist Resume Examples & Samples

Provide general administrative support to the Provider Contracting department, including typing, scheduling, and coordinating services
Support Humana’s providers and communicate with Humana’s clients in order to facilitate greater physician understanding and cooperation during the contracting process
Prepare, assemble and mail contracts on behalf of Humana, tracking the contract’s activity and regularly reporting its status
Maintain all provider contracts and credentialing files
Prior experience in an administrative support role
Comprehensive knowledge of Microsoft Office applications
Prior health care industry experience in the areas of contracting or operations

Provider Relations & Contracting Manager Resume Examples & Samples

Strategically manage in-force provider contracts, sharing Humana’s value proposition through frequent contact and education and proactively administering the relationship process
Implement local strategic plans in order to effectively influence providers, provider affairs and service centers
Ensure that retention rates and positive negotiations meet and regularly exceed network targets
Contribute to the training and development of other associates in the Provider Contracting area
Manage multiple projects, collect and analyze data and disseminate to appropriate departments as necessary
Bachelor’s Degree in Business, Finance or a related field or a minimum of 3 years’ relevant business experience
Prior demonstrated success in provider contracting or provider relations
Prior experience in a management role

Provider Relations Manager Resume Examples & Samples

Oversee a team which analyzes and identifies key claims processes that need to be improved
Identify and resolve barriers to performance from determining root cause analysis, creating process mapping and resolution – implementation
Oversee the improvement process
Progressive levels of responsibility related to claims processing
Comprehensive knowledge of all Microsoft Office applications, including Word, Project and Visio

Bill Review Provider Relations Specialist Resume Examples & Samples

Working knowledge of Strataware/CompIQ, and/or Call Track
Understanding of State rulings and regulations as relating to Workers’ Compensation
Understanding of medical bill processing rules and guidelines
Provide prompt, courteous and accurate customer service
Perform administrative tasks such as managing faxes and phone message retrieval within 24 hours
Facilitate the processing of “PRIORITY” request to ensure that bill review processors make the necessary changes with 48 hours
Demonstrate the ability to work both individually and in a team environment
Respond to provider issues and direct problem resolution
Set an example of courtesy and professionalism for all co-workers and customers
Complete additional work assignments as required by management
Demonstrate the ability to use Stratraware/CompIQ and Citadel to locate claim information (by social security number, claim number or patient name) to provide current status (check information, authorization and/or compensability)
Analyze Call Track data to determine that the information gathered is correct and calls can be resolved
Maintain a schedule adherence rating of 95% or higher
Maintain a quality level of 3.0 or higher (scale 1-5)
Demonstrate an understanding of the Bill Review guidelines and procedures
Demonstrate professional attitude and communication at all times with coworkers
Adhere to the Bill Review Department Dependability guidelines
Ability to learn ICD-9/10 and CPT coding
Ability to use Microsoft Windows-based software
Ability to learn and apply basic medical terminology
Good oral and written skills
Ability to assess and document reconsideration issues
Minimum one (1) year of Customer Service experience or six months of Medical Bill Review processing
Two (2) years experience in Customer Service Department
Two (2) years experience in Workers’ Compensation
Two (2) years experience in a medical setting
Six (6) months experience in Bill Review Department

Provider Relations Leader Resume Examples & Samples

Health care or managed care with Provider Contracting, Network Management or Provider Relations experience
Demonstrated management experience and partnering with senior leadership on strategic initiatives
Ability to travel with Provider Service Consultants to provider offices in the Memphis and surrounding areas as needed
Bachelor's degree strongly preferred
Proficiency in analyzing and interpreting financial trends for health care costs, administrative expenses and quality/bonus performance
Comprehensive knowledge of Medicare policies, processes and procedures

Bilingual Provider Relations Specialist Resume Examples & Samples

Updates and maintains on network tracking system the current status of pending and renewing vendor applications
Schedules and organizes outreach presentations and serves as educator/liaison with providers to ensure providers are current on HAEC programs, policies & procedures, billing practices, accessibility standards and contracted service requirements
Responds to corporate office requests to obtain updated status on pending contracts and outstanding documentation and/or compliance issues
Attends trade organization events, conferences and business networking meetings on a regular basis to market HAEC products and programs
This role is part of Humana’s Driver safety program and therefore requires an individual to have a valid state driver’s license and proof of personal vehicle liability insurance with at least 100,000/300,000/100,000 limits
Must have a separate room with a locked door that can be used as a home office to ensure you have absolute and continuous privacy while you work
Must have accessibility to high speed DSL or Cable modem for a home office (No Satellite)
One to three years related experience
Must be bilingual (Spanish and English)
Must possess strong communication skills, both verbal and written
Excellent interpersonal s. ls
Knowledge of all Microsoft Office programs

Director of Provider Relations & Network Development Resume Examples & Samples

10+ years of experience working in a Healthcare environment; 5+ years of Management experience
Bachelor’s Degree in Business or related field
Managed Care Contract development and negotiations experience
Solid knowledge and understanding of the Managed Care industry and local market conditions
Strong working knowledge of current Healthcare Market trends and products available in the community
Working knowledge of Medicare and Medicaid programs
Previous experience with HMO / PPO

Provider Relations Specialist Resume Examples & Samples

Refers to reference library of fee schedules, CPT, ICD-9, HCPCS and other industry publications to research and support findings
Communicates with State’s Workers’ Compensation agencies
Assists and cooperates with co-workers, supervisor and management
Retrieves data and prepares reports
Identifies problems, provides solutions and resolves promptly. Escalates more complex problems to the next level
Demonstrates a dependable work ethic
Collaborates with supervisor to develop skills and knowledge
Comprehensive knowledge of the Official Medical Fee Schedule and California medical/legal schedules
Familiarity with other States’ Rules and Regulations
Previous experience in workers’ compensation industry
Ability to read, learn and retain Workers’ Compensation regulations
Proven ability to build/maintain relationships at all levels
Effective oral, written and communication skills
Good organizational skills

Provider Relations Liaison Resume Examples & Samples

Bachelor’s degree and a minimum of two years related experience
Must be highly organized with a strong ability to juggle multiple projects in a fast-paced environment
Must be a strategic thinker, excellent writer, clear and concise communicator
Must have strong analytical abilities

Provider Relations Senior Analyst Resume Examples & Samples

Creates supporting marketing & education materials for all operational initiatives intended for a wide range of audiences
Provides marketing materials, communications, and project execution support for the entire life-cycle of initiatives/campaigns
Provides editorial and writing expertise for marketing collateral development, internal and external websites, newsletters, and press releases
Executes detailed project plans and regularly provides appropriate analysis and reporting on key initiative metrics, tracking progress relative to goals
Provides recommendations for innovative projects and processes to help improve deliverables
Prioritizes, plans, and facilitates marketing projects for local dialysis facilities
Evolves communication strategies to ensure DaVita is well positioned to address traditional and emerging communication channels, methods, and media
Provides education and communication to physicians and their offices on planned benefits, contracts, and reimbursements
Minimum of five years of experience in healthcare operations or a business setting
Health plan experience preferred

Provider Relations Manager Resume Examples & Samples

Supports SNP implementation locally; collaborating with key implementation stakeholders
Manage the various accounts and internal/external relationships associated with the SNPs; develop new and maintain existing physician relationships with Nephrologists and other providers participating in VillageHealth Government programs
Accountable for SNP membership, physician networks, monthly reporting, team communication, and administrative functions
Develop and maintain relationships with health plan partners to pull all non-clinical levers to improve plan and product performance
Deliver executive level presentations to key stakeholders inside and outside of the DaVita Healthcare partners organization
Develop knowledge of competitive products and external factors in each market
Bachelor's degree in related area required; MBA preferred
Minimum of four (4) years' project management and operational experience required
Demonstrated experience working with multi-disciplinary teams
Demonstrated ability to analyze problems/issues, gather data and information, evaluate and recommend alternative solutions
Strong negotiation, problem-solving, decision making and influencing skills to work with people across enterprise and partners, garnering input and buy-in
Advanced computer proficiency and skills in MS Excel, PowerPoint, and Word required; intermediate proficiency in Outlook required
Ability to enhance relationships through strong and effective communication, problem solving and decision making
Superior verbal and written presentation skills - comfortable making business presentations to operational and clinical groups
Excellent communication skills and experience converting ideas/concepts into tactical execution
Willingness to Travel (25%)

Manager, Provider Relations Resume Examples & Samples

Leads and develops a team of Provider Relations Representatives and Provider Operations Coordinators
Performs data analysis and develops specific actions to manage medical cost trend
Bachelor's Degree in a related field is preferred or equivalent work experience is required
5+ years of experience in Provider Relations or similar background is required
3+ years of experience in Management, Supervisory, or Lead/Sr. role with demonstrated leadership ability or program management experience is required
HMO/PPO background is preferred
Ability to lead/manage others
Knowledge of healthcare delivery Strong functional and technical knowledge of healthcare delivery
Ability to influence internal and external constituents
Financial skills
Knowledge of CMS and state regulations
Microsoft Excel is required *LI-RG1

Provider Relations Coordinator Resume Examples & Samples

On-board new physicians via in-person meetings to present the Steward Health Care Network structure, available resources, and reference materials
Set-up access to the Steward network and Steward applications for physicians and practice staff
Partner with practice staff and act as a single point of contact to field and resolve physician/practice questions/issues regarding fee schedules, referral simplification, patient population confirmations and other ad hoc network projects by coordinating across Steward teams to ensure task completion and/or resolution
Provide training on Steward applications on an as-needed basis to practice staff and physicians
In conjunction with provider enrollment, help physicians maintain current contact and practice information in the Steward provider database that feeds the web-based tools used by patients to contact and select Steward providers
Provide practices with both requested and network distributed reports
Assistance practices with the maintenance of referral lists
Act as content expert on claims and enrollment data to support practice population health management
Coordination of Chapter leadership Board meetings including but not limited to meeting logistics, preparation and distribution of meeting materials and official meeting minutes to be filed with the regional board for approval
Coordination of Chapter POD and office manager meetings
Demonstrated ability to work independently and as a team
Familiarity with Microsoft Office software (Word, Access, Excel, PowerPoint)
Knowledge of general office machines and telephone system
Ability and willingness to work cooperatively with others
High degree of discretion dealing with confidential information

Provider Relations Senior Specialist Resume Examples & Samples

Attends scheduled training sessions of other payers, vendors, professional associations as requested
Follows-up on issues raised at any training session, including contacting Provider Associations with updated information, and updating future training protocols and materials
Conducts state-of-the-art training sessions and seminars in locations throughout Massachusetts, including the provider’s office when requested and appropriate
Develops educational messages and materials for existing Providers to promote understanding of policies and procedures as well as good business practices
Create educational sessions that can be made available to providers via the customer Web Portal
Plan, develop and implement an account management strategy for assigned MassHealth Programs
Forms and utilizes interdepartmental communication workflows, protocols and relationships to coordinate all Provider support within the MassHealth Customer Service Team
A Bachelor’s Degree from an accredited college or university, equivalent experience considered in lieu of degree
Minimum 2 years related work experience required
Track record of accomplishment
Formal public speaking experience
Excellent organizational, communication and interpersonal skills
Demonstrated leadership qualities
Understanding of common provider issues including billing practices, claim operations, enrollment and credentialing, and health care trends
Proficient in Microsoft Office (PowerPoint, Word, Excel and Outlook)
Ability to perform comfortably in a fast-paced, deadline-oriented work environment
Ability to work as a team member, as well as independently

Associate Provider Relations Coordinator Resume Examples & Samples

Resolve operational issues that are routed to the Provider Relations team either telephonically or via e-mail
Review and approve expense reports submitted by the HouseCalls Providers
Assist with the creation and completion of travel requests for HouseCalls Practitioners
Assisting with outbound calls to ensure practitioners have loaded required hours of availability
Provide assistance to HouseCalls Practitioner field by quickly and efficiently addressing practitioner concerns
Assist with the composition and review of production based reporting for HouseCalls regions
1 + year of MS Excel - basic formulas, analyzing data, filtering and sorting
Any experience with Workforce Management or Operational Support
Experience with Data Analysis
1 + year of Customer Service experience
Associate's Degree or Higher

Provider Relations Coordinator Resume Examples & Samples

Supporting all contracting solicitation and enrollment efforts. Working closely with Provider Contracting and Retail Network Operations
Primary Phone Coverage for the Provider Relations Escalation Hotline
Answering occasional e-mails, and Pulse tasks coming into the department from Pharmacies and internal departments
Supporting pharmacies and internal Catamaran departments with pricing, reimbursement, and claims processing inquiries
Developing and maintaining a positive relationship with contracted pharmacies, and coordinating effectively with internal and external partners to ensure pharmacy inquiries are handled and resolved in an accurate and timely fashion
Utilizing the Provider Relations Tracking Database and log all calls coming in
Projects as assigned
Mailings as needed for communication
1+ year experience the pharmacy benefits management (PBM) business
Intermediate level with Microsoft Word, Excel, and Access
Phone Customer Service experience
RX Claims experience

Senior Provider Relations Hospital Advocate Resume Examples & Samples

Translate concepts into practice
Proficiency with MS Word, Excel
Ability to travel regionally about 5% of the time
Proficiency with MS PowerPoint and Access
Knowledge of Medicare and Medicaid regulations
Experience with UNet, COSMOS, NDB
Experience with medical coding, or medical coding certification

Provider Relations Contracting Representative Resume Examples & Samples

Analyzes current network and projected network needs from cost/utilization, competitor and member access standpoints and develops and implements contracting activities as indicated
Participates in contract mailing preparation, makes and receives provider calls, time manages daily work activities to meet longer-term project goals and timelines
Keeps detailed and accurate notes regarding all negotiation efforts in the Tracking database
Prepares instructions for fee schedule and contracting loading that accurately reflect contract language, rates and intent
Works cross-functionally with other departments to remove barriers impeding contract negotiations, manage contract implementation, identify opportunities for process improvement and facilitate problem resolution
Performs other responsibilities as assigned for special projects and escalated issues
Two years experience in a contracting/negotiation setting, provider contracting preferred, or health care/medical office environment
Experience in conducting data analysis and creating reports in Excel
Experience with AHCCCS a plus
OR, any combination of academic education, professional training or work experience, which demonstrates the ability to perform the duties of the position
Solid understanding of health plan products/lines of business, familiar with basic medical contracting methodologies and claims pricing/reimbursement strategies. Familiarity with AHCCCS preferred
Accuracy and detail orientation are required
Proficiency with Microsoft Word, Excel and PowerPoint required; knowledge of Microsoft Access, ABS, MACESS is beneficial
Excellent customer service and verbal and written communication skills
Strong analytical skills and ability to use advanced features of Excel to run data analysis and create insightful and professionally presented reports

Senior Provider Relations & Contracting Representative Position Must Work From Locat Resume Examples & Samples

Effectively analyzes and negotiates contract rate and language proposals, independently solves problems and prioritizes work
Analyzes current network and projected network needs from cost/utilization and competitor standpoints
Provides strategic input on contracting targets and rates for various projects
Makes and receives provider calls, negotiates, time manages daily work activities to meet longer-term project goals and timelines
Keeps detailed and accurate notes regarding all negotiation efforts which may include in the Tracking database as required
Prepares requests for fee schedule and contract loading that accurately reflect contract language, rates and intent, if applicable
Takes lead on escalated issues from assignment through closure
Two or more years contracting experience in healthcare
Or any combination of academic education, professional training or work experience, which demonstrates the ability to perform the duties of the position
Solid understanding of health plan products/lines of business, familiar with basic medical contracting methodologies and claims pricing/reimbursement strategies
Knowledge of Microsoft Word and Excel required, knowledge of Microsoft Access, ABS, MACESS a plus
Ability to maintain professionalism in response to escalated provider calls

Provider Relations Coordinator Resume Examples & Samples

Ensure appropriate and effective communication with the Clinical Team Managers in the field within assigned territory
Conduct market specific analysis to manage capacity according to current production requirements and constraints
Responsible for assuring practitioners have loaded required hours of availability and assignments are made in a timely fashion
Execute practitioner assignments that ensure target outcomes are achieved within assigned territory
Ensure effective communication with other teams to assure Provider Relations issues are managed quickly and efficiently
Monitor production in assigned territory and work with key stakeholders to develop and maintain strategies that address deficiencies
Submit timely and accurate reports regarding production in assigned territory
Provide quality assistance to HouseCalls Practitioner field by quickly and efficiently addressing practitioner concerns
Achieve performance metrics related to telephonic quality assurance
Ability to work an 8 hour schedule starting between 8-11 am and ending between 4:30-7:30 including occasional weekends
Experience with Microsoft Excel (Creating spreadsheets, VLOOKUP, pivot tables, etc.) and Word (Creating, and updating documents)
Bachelor's Degree (or higher) in a business area or health administration field
2+ years of workforce management experience (i.e. responsible for scheduling, call volume monitoring and adjusting, determining and communicating work schedules and resources for call queues, consulting with call operations, etc.)
1+ year of operations support experience

VP, Network Strategy & Provider Relations Resume Examples & Samples

Partners with field network teams and key shared services stakeholders to advance the execution of the Company’s value-based contracting strategy
Designs new contract model templates to support Market business priorities. Collaborates with field network teams, Legal, Finance, Operations, Compliance and other key stakeholders to ensure templates are compliant, clear to providers, and able to be administered
Coordinates monthly communication forums with each State’s Network Leadership Team to ensure bi-directional flow of information on key issues, identify market support needs, and facilitate sharing of best practices
Chairs recurring weekly Network Advisory Group (“NAG”) meetings. Identifies agenda topics that are relevant and focuses on key issues requiring stakeholder discussion. Works with presenters and other stakeholders in advance of meetings to ensure content of meeting materials is complete and supports driving to consensus and decision-making on important topics
In collaboration with field network teams, design and execute major projects related to provider engagement and network solutions, including but not limited to continued evolution of Company’s Provider Engagement Model, Provider Contract Automation project, and Practice EMR Connectivity
Oversees all standard KPIs and metrics related to value-based contracting and strategic network solutions (e.g. EMR connectivity; E2E Contract TAT) to support comprehensive department reporting package overseen by Network Performance. Acts as “Business Owner” for these specific metrics to ensure accuracy and proper context for Senior Leadership
Partners with Public Policy and local Government Affairs Teams to track and monitor emerging legislation related to provider networks (and specifically, value-based contracting). Assesses impact of legislation on WellCare’s business and leads the implementation of any corresponding action plans to respond
Partners with Business Development Team to support early-stage activities in new “greenfield” markets related to identifying (and in some cases, contracting ) with key provider partners to support WellCare’s RFP responses
Supports Company Merger & Acquisition opportunities via participation in upfront evaluation (due diligence) activities and post-closing integration activities as directed by VP, Corporate Network Performance
Leads early stages of negotiations for new provider partnership opportunities (e.g. new value-based models; national contract frameworks requiring cross-market coordination). Owns and maintains all Company policies and procedures related to value-based contract and other strategic network topics
Preferred A Master's Degree in
Required 10+ years of experience in Managed Care Organization
Required 7+ years of experience in network management, hospital contracting, ancillary contracting and provider contracting
Required 5+ years of management experience With proven track record of health care industry experience
Advanced Ability to analyze information and covert related activities into a comprehensive work plan
Advanced Knowledge of healthcare delivery
Advanced Ability to implement process improvements
Advanced Demonstrated leadership skills
Advanced Demonstrated problem solving skills
Preferred Advanced Microsoft Excel

Provider Relations Development Specialist Resume Examples & Samples

Assists provider relations representatives in the research and resolution of claims issues
Provide feedback to manager regarding education and resources needed to resolve claim issues
Performs monthly technical assessments of all Provider Relations representatives and provider operations coordinators and provide feedback and recommendations to manager for performance improvement
Participates in ride along with PR Reps and POCs to provide feedback and recommendations to managers on performance improvements
Completes new provider orientation for key provider groups, facilities and large IPAs, and ancillary providers for Medicaid, Medicare and state children's program product lines
Conducts new office orientations and continuous face-to-face service/educational meetings to ensure provider and staff understand company policies and procedures
Understands and explains risk contracts
Manages incoming provider inquiries: identify potential claims trends and follow-up with provider and internal departments to ensure that identified problems have been resolved
Manages the physician/provider re-credentialing process including (as needed) Site Survey visits
Works closely with the In-house Provider Relations staff regarding educational needs, claims issues and contracting questions
Serves as team lead, resource for Provider Relations Team
Support Regional Network Improvement Plan targets by providing network physicians and identified cohorts with physicians utilization reports, Pharmacy profiles, ER frequent flier reports and other analytics available to improve/maintain regions medical loss ratio goals
Identifies network gaps and work with internal partners to complete contracts
Reviews Encounter Database for zero encounter submitters and educated providers accordingly
Responds to regulatory bodies as required (for grievances/appeal inquiries)
Participates in quarterly compliance audits for AHCA and accrediting agencies
Identifies potential new providers and communicate need to Network Development Team
Reviews and discusses HEDIS information with Primary Care Physician
5+ years experience in Provider Relations, within large group providers, facilities, IPAs or similar background is required
1+ year experience in government programs is preferred
Experience in Pharmacy, healthcare, provider or HMO/PPO background is preferred
Ability to understand and explain complex negotiations
Ability to understand complex claims analysis
Demonstrated people management and facilitative skills
Excellent interpersonal skills and demonstrated ability to influence internal and external constituents
Strong knowledge of CMS and state regulations
Proficient in Microsoft Office such as MS Word, MS Excel and MS Outlook
Proven analytical and financial skills *LI-RG1

Senior Provider Relations Specialist Resume Examples & Samples

Work in conjunction with Provider Network Manager and Director of Network Development to achieve organizational goals regarding PSHP’s provider network. Analyze and make decisions regarding provider contracting in existing service areas, including decisions to contract, decisions not to contract, and at what unit cost within defined parameters
Support medical management through negotiation of spot contracts for non-participating providers
Make presentations to provider groups and communicate directly with provider group representatives regarding policies and procedures, and provider based initiatives
Cultivate and maintain collaborative internal and external business relationships
Provide support to internal and external customers
Work collaboratively with individuals responsible for delegation oversight to assure accreditation and regulatory compliance standards are consistently met
In conjunction with medical management team, identify any areas of concern regarding medical cost targets and develop action plans related to those areas
Follow up on new leads and referrals resulting from field activity
Prepare presentations, proposals and contracts
Develop, maintain and distribute provider materials, including website content
Maintain current product knowledge including an understanding of the competitive environment
Identify and resolve provider concerns
Communicate new service opportunities, special developments, information, or feedback gathered through field activity to appropriate company staff
Develop and implement special activities
Provide support to marketing events such as seminars, trade shows, and telemarketing events
Proficient in use of Microsoft Outlook, Word, Excel, and Powerpoint and strong analytical skills
Aptitude for developing and delivering presentations
Ability to use strong interpersonal and communication skills to persuade and influence others
Ability to create, compose, and edit written materials
Demonstrated creativity in development of materials, communications, and problem solving
Maintain a professional appearance and provide a positive company image to the public
Significant local travel to current and potential provider locations requires possession of a valid state drivers license and a reliable vehicle
Event planning and coordination skills
Demonstrated understanding of provider delivery systems, contracting strategies, reimbursement systems
Solid working knowledge of Medicare policies, programs, and procedures, and previous experience working with Medicare contracts is preferred
Willingness to work a flexible schedule and occasional overnight travel

Provider Relations Director Resume Examples & Samples

Works collaboratively with Sales and Solution Management to lead the development of client specific solutions that result in positive outcomes
Serves as the Engagement Manager on specific client accounts, taking complete responsibility for client outcomes
Develops sustainable business strategies and ensures they are implemented to meet company goals
Preferred candidate will have a combination of a client-service orientation combined with a demonstrated ability to assimilate and lead in a high-growth entrepreneurial environment
Strong management and leadership skills and will lead by example, motivating through intellect and experience
Experience in building and leading a team for success in the marketplace and operating in a high energy environment
Strong oral/written communication, organization and interpersonal skills, combined with effective negotiation skills and a demonstrated effectiveness in a managerial role are required
Deep understanding of the buying process and unique healthcare needs of either employer / union purchasers or providers (e.g., health systems) is required
Demonstrates industry knowledge and emerging thought leadership and expertise and shares that knowledge with the team and clients
5+ years’ client operations experience within the healthcare sector, account management for vendors serving healthcare clients, or similar experience related to technology-enabled solutions is required
Master’s degree in business or healthcare field is preferred

Provider Relations Liaison Resume Examples & Samples

Bachelor’s degree in business-related or fitness discipline or equivalent additional experience
Two years or more working in healthcare or fitness-related field is required
Fitness center management/operations and network development highly desired
In-depth knowledge of fitness industry
Effective public speaking and presentation skills
Strong time management and organization abilities
Willingness and ability to travel (up to 30%)
Able to handle multiple and changing priorities in a fast-paced environment
Proficient in Microsoft Office products (Word, Excel, PowerPoint, Outlook)
Proficient in the use of the Internet as a communication tool and research resource

Provider Relations / Contracting Specialist Resume Examples & Samples

Bachelor's degree in Business Administration or related field preferred
Strong analytical/quantitative skills
Two to three years’ experience working in health care contracting – managed care environment preferred
Two to three years’ experience working in physician practice management or a clinical setting preferred
Knowledge of health care and managed care contracting
Proficient in use of Databases and queries, software tools such as Excel, Pivot Tables, Powerpoint,
Proficient in healthcare terminology (CPT4 codes, contracting terminology) preferred
Excellent organization skills and communication skills (both verbal and written)
Ability to work under deadlines and tolerate a heavy workload
An upbeat, positive, and “can do” attitude

Provider Relations Consultant Resume Examples & Samples

Anticipate customer needs and proactively develop solutions to meet them
Serve as a key resource on complex and / or critical issues
Solve complex problems and develop innovative solutions
Communication with external providers and Health Plan CEOs
Establish key relationship through the enterprise, network, and member community to drive long-lasting results
7 years of provider relations and / or network management experience
7 years of experience with Medicare and Medicaid regulations
Intermediate level of proficiency with claims / systems processes, contracting and reimbursement methodologies
Extensive experience in a healthcare / clinical setting
Master’s Degree and / or RN
Sound Project Management Skills

Associate Provider Relations Coordinator Resume Examples & Samples

1+ years of experience with Microsoft Excel (basic formulas, analyzing data, filtering and sorting)
Available to work from 11:00 am to 7:30 pm Monday through Friday
Associate's Degree or higher
1+ years of Customer Service experience

Provider Relations Consultant Resume Examples & Samples

At least an intermediate level of knowledge of claims / systems processes, contracting and reimbursement methodologies
5+ years of experience with Medicare and Medicaid regulations
At least an intermediate level of proficiency with MS Word, Excel, PowerPoint

Credentialing Coordinator Uninet Provider Relations Days CHI Health Service Center Resume Examples & Samples

Provides leadership and oversight in development of credentialing functions in direct support for the integrated delivery system
Works with physician offices to attain correct information on physicians. After receiving information, is responsible for accuracy of all information in credential files of all physicians in UniNet
Coordinates physician applications to UniNet and receipt of credential files from Nebraska Credentials Verification Organization (NCVO)
Ensures compliance and adherence to NCQA standards of functions and responsibility related to credentialing for UniNet
Develop, update, and coordinate the implementation of Credentialing policies and procedures for final approval by the Credentials Committee, the Business Management Council and the Board of Directors, as needed
Coordinate with Executive Director, Provider Relations, and Credentials Committee any peer review process of a physician assuring appropriate due process is followed according to the Fair Healing Plan of UniNet. Assure confidentiality of this information is maintained, and exercise discretion and latitude in the preparation of personnel regarding such issue
Manages credentialing and recredentialing process for UniNet
Coordinates and prepares for payor audits of UniNet credentials files for those networks which accept credentialing by the provider organization
Processing and database or spreadsheet software is highly desirable. Experience working with computers in Windows environment preferred

Manager, Provider Relations Resume Examples & Samples

Conducts ride-alongs with Reps. in the field to develop skills and behaviors and document progress/provide formative feedback through timely and consistent Field Trip Reports
Must be able to travel up to 50% in assigned market
Preferred a Bachelor's Degree in a related field
Preferred HMO/PPO background
Intermediate ability to lead/manage others
Advanced knowledge of healthcare delivery
Strong functional and technical knowledge of healthcare delivery
Advanced ability to influence internal and external constituents
Advanced demonstrated analytical skills
Intermediate facilitative skills
Advanced financial skills
Advanced knowledge of CMS and state regulations
Required Advanced Microsoft Word

Manager, Provider Relations Resume Examples & Samples

May oversee work activities of other supervisors
Product, service or process decisions are most likely to impact multiple groups of employees and / or customers (internal or external)
Leading Joint Operation Committee with network providers
Day to day interactions with the provider network
Monitoring and ensuring compliance with regulatory requirements
3+ years of provider relations and / or network management experience
3+ years of management experience
Advanced level of proficiency with MS Word, Excel, and Access
Good organization and planning skills
Advanced level of knowledge of claims / systems processes, contracting and reimbursement methodologies

Provider Relations Coordinator Resume Examples & Samples

6+ months of work or educational experience with interpreting and summarizing large data sets to drive informed actions
6+ months of work or educational experience sourcing data, and analyzing, trending and producing a forecast from findings
6+ months of Microsoft Excel experience working with Pivot Tables, v-lookup, sumif etc
Bachelor's Degree (or higher) in healthcare, business or other related field
Professional experience in operations, workforce management or data analysis
Professional experience in data modeling, trending and forecasting

Provider Relations Program Coordinator Resume Examples & Samples

Responsible for coordinating large scale mailing activities for the distribution of provider media materials, publications, amendments, provider manual updates. Works with external vendors and coordinates handoffs to ensure publication timelines are met
Maintains and updates Provider Relations project and timeline trackers. Assists in ensuring project deliverables are timely
Provides technical and task assistance in the development of training, media materials, and the implementation of content updates to the Community Provider Portal
Responsible for gathering content for the provider newsletter. Works closely with Network Education and Media Specialist in developing content for articles
Schedules project meetings and venues. Ensures meeting resources and materials are present for meeting participants
Coordinates regular provider network surveys within designated timeframes. Gathers survey data and responses. Works with external vendors when appropriate
Manages Provider Relations mail and correspondence. Directs correspondence to appropriate Provider Relations teams
Provides administrative support to Sr. Manager, Provider Relations and Supervisors as requested
Minimum of three (3) years of professional experience in a healthcare organization required, but preferred in managed care
Minimum of two (2) years of clerical/customer service position with excellent interpersonal-relations skills, and command of the English language required
At least one (1) year of active experience with use of Microsoft Office suite, Internet Services, and Access required
Prior experience Provider Relations experience highly preferred
Bachelor's degree is preferred
Additional education and data systems training are preferred

Provider Relations Specialist Resume Examples & Samples

Identifies and establishes relationships with key providers involved in delivering an effective care delivery model to ESRD patients
Establishes a routine communication cadence with key providers in order to communicate initiatives and outcomes
Ensures effective problem resolution, and facilitates communications between providers and payor partners
Provides recommendations for innovative projects and processes to help improve deliverables and/or existing processes
MINIMUM QUALIFICATIONS
Bachelor's degree in business or related field preferred
Minimum of three years of experience in healthcare operations, provider relations, or a business setting
Health plan, health system, or provider group experience preferred

Senior Provider Relations Resume Examples & Samples

In collaboration with division and/or market clinical and business development leaders, evaluate, analyze, and interpret market utilization data for market facilities' service line, ensuring that sales priorities are identified in line with the vision and strategic goals of the Behavioral Health service line
Evaluate, analyze, and interpret market demographics, including population, age, gender, race, and projected trends for both physicians and patient populations
In collaboration with division and/or market CEO's, evaluate, analyze, and interpret current physician and key non-physician referral patterns and trends for market facilities' service line, ensuring that sales resources are optimized
Selling of service line attributes, processes, and outcomes to consumer, physician, and market facility groups/individuals
In collaboration with division and/or market physician services, facility leaders, medical staff leadership and facility physician development teams develop sales and retention strategies for target markets and facility Behavioral Health services
Develop goals and timelines for closing new or enhanced physician and key non-physician referrals
Execute sales and retention strategies and plans; successfully close new business in accordance with predetermined targets
Complete face-to-face sales meetings with physicians and practice managers, and key non-physician referral sources ensuring that a thorough understanding is gained regarding the physicians'/referral sources' desires and needs
Complete follow-up meetings with physicians, practice managers, and/or other key referral sources as needed to close new or additional business, ensuring that internal and external obstacles to business growth and retention are identified and minimized or eliminated
Prepare and present monthly sales reports, identifying trends, additional business opportunities, and obstacles to retention and new business growth
Continuously modify sales and retention strategies and plans to ensure optimal business outcomes and "win-win" results for physicians, key non-physician referral sources and company market providers for the service line
Attend service line specific medical staff meetings
Ability to access, understand, and explain physician and key non-physician referral patterns
Ability to plan, organize and manage resources within prescribed timeframes (prioritize and focus)
Ability to present, probe and persuade
Ability to identify and respond appropriately to primary client/customer needs (service orientation)
Ability to demonstrate effective listening and communication skills
Ability to close
Ability to provide follow-up and demonstrate attention to detail
Ability to prepare and present executive reports
Ability to actively listen to physician and key non-physician referral source practice needs for hospital inpatient and outpatient services

Associate Director, Provider Relations Resume Examples & Samples

Provider Relations and quality compliance oversight
Oversight of Provider Relations Representatives Specialists
Coordinate monthly LTSS Provider Review Committee meetings to review provider quality of care issues and recommend actions for enrollment, credentialing and revalidation findings
Summarize committee findings in a monthly LTSS Provider Review Committee report and an annual Provider Review Summary Report
Training of internal staff and external LTSS Providers
Review monthly quality reporting - Call Center, turnaround times, enrollment activities, credentialing/revalidation activities and coordinates reporting to EOHHS
Work with Quality Improvement Committee to develop and implement appropriate corrective action plans
Assist with LTSS provider communications
Use risk management and patient safety data to identify and implement quality improvement, for example, prompt identification and handling of member abuse, neglect, and/or exploitation
Provide coverage for RN Utilization Management Lead and Appeals Coordinator
Bachelor’s Degree of Nursing
Minimum of 5 years clinical nursing experience inclusive of Provider Relations and Quality Improvement experience
3 years in a management / supervisory role in in a managed care environment
Solid computer skills
Effective communication skills, flexibility and displays positive attitude

Provider Relations Consultant Senior Resume Examples & Samples

Builds relationships with providers and establishes effective communication methods between the providers, management and internal staff
Recruits and outreaches to potential providers
Assists current providers in expanding their existing services and/or areas of service
Conducts initial and on-going site visits and quality audits for credentialing/re-credentialing purposes
Orientation and training of new providers to ensure understanding of Amerigroup’s expectations and of the CHOICES/ECF programs and/or services
Provider Advocacy and Issues Resolution (billing/claims etc.)
Maintain current list of active, assigned providers for CHOICES and ECF CHOICES and all related information
Participate in regional conferences, expos, training and community outreach events
Assisting in quality monitoring by participating in DIDD exit interviews, HCBS Settings assessments and Heightened Scrutiny reviews
Tracks trends in area provider issues, service needs, deficiencies, and training/education opportunities
Maintains ongoing communication with regional Support Coordinators and Care Coordinators for fluidity of programs
Ensures accurate and timely submission of expense reports

Provider Relations Coordinator Resume Examples & Samples

Create and maintain documentation in support of the project management lifecycle, including project workspaces, organization charts, distribution lists, meeting minutes, project action items, issues and risks, project schedules/plans, budget tracking, and status reports
Provide logistical support to the project management team, including scheduling meetings, preparing and distributing meeting materials, and managing all available meeting technology
Work with project team members to develop clear, complete and accurate project specifications and deliverables
Develop and document operational workflows to carry business objectives through execution and ultimately future/steady state
Act as a liaison between department and project management software or key project personnel
Develop and maintain publication standards for project deliverables
Assist in ensuring compliance with departmental policies
Act as lead for smaller projects

Division VP-physician & Provider Relations Resume Examples & Samples

Manage, develop, and evaluate sales and facility staff to achieve measurable sales objectives
Develop collaborative relationships between division and hospital administrators to increase sales efforts
Track and manage sales reports in the database management tool
Oversee recruitment selection, and training of all new Sales Representatives
Communication - Communicates clearly and concisely, both verbally and in writing. Extensive and documented experience in communicating with top executives and physicians
Mobilizing Resources - Ability to manage staff and resources consistent with organization goals
Sales Ability/Persuasiveness - Using appropriate interpersonal styles and communication methods to gain acceptance of a product, service or idea from prospects and clients. Ability to sell to internal and external customers
Operational Decision Making - Demonstrated sales staff management skills. Highly experienced and competent in sales management and infrastructure development
Requires seven to ten years of sales management experience
Seven to ten years of sales management experience in healthcare strongly preferred

Contracting & Provider Relations Resume Examples & Samples

Lead teams in the delivery of high-quality programs and solutions that meet business needs
Create detailed project design documents and task-level project plans to organize cross-functional teams
Partner closely with other members of functional project teams to define business requirements
Support and assist NNO VP and Directors to support overall strategy and development of priority projects
Support current NNO and market network strategy through project development, implementation and management (i.e. trendbending, MTC, credentialing initiatives (decreds, delegated affiliations, extenders), network strategy surrounding network expansion and targeted contracting/credentialing, development of market specific audit processes/tools)
Identify accountable associates and stakeholders to ensure progress, timelines and project completion is met
Communicate/train all stakeholders on projects and provide ongoing, critical updates to include mitigation of risk
Identify, collaborate and develop departmental process improvement to support innovation and efficiency
Bachelor’s Degree or relevant 2-3 years of experience
Prior experience managing mid to large scale and diversified projects
Prior/current provider contracting/provider relations experience
Proficient in Microsoft Applicatons with Advanced Excel skills
Effectively manage cross functional teams through project completion
PMP and/or Six Sigma certification
Project Management Institute certification
Previous experience planning and managing large projects
Prior experience in the health solutions industry

Provider Relations Liaison Resume Examples & Samples

Develops and maintains provider manuals appropriate to each provider network
Conducts on-site in-services for new and existing providers and their staff to ensure that the office staff know what information is contained in the manual as well as the HCP processes for eligibility, authorizations, complaints, claims submission, etc
Re-orients providers and office staff, as needed, when HCP or HMO processes change or when additional processes are implemented
Keeps providers and office staff informed of changes in HMO plan benefits or programs as appropriate
Resolves provider issues by interfacing with HCP central departments including Contracting, eligibility, Claims and Finance
Serves as a point of contact to central departments for issues related to the network. Communicates any relevant information from the central departments to the network when necessary
Responds to and resolves questions or concerns from providers or their office staff in a timely and service-oriented manner
Recognizes network issues and brings these to the attention of the Director and/or RAT
Reports operational issues, statistics progress toward goals and potential barriers to the Director of Network Operations/Regional Vice President on a monthly basis
Assists with the credentialing of new physicians. Contacts physician to request necessary paperwork, keeps them updated of their status, and once credentialed and contracted, advises them of their status with the plans
Completes and routs paperwork to add, delete and/or change providers’ demographic information
Maintains current and accurate roster of primary care and specialty providers for each provider network
Issues and distributes quarterly IPA Bulletin that contains relevant articles and announcements to networks
Promotes enrollment growth by working with the health plan representative, community organizations, providers and HCP marketing representatives. Attends health fairs and other community outreach programs when necessary
Plans valuable educational programs for the network office staff on an as needed basis
Prepares agenda, leads meetings and takes minutes for certain specialty JOC meetings
Works closely with the Director/VP to enhance physician satisfaction
Collaborates with the Director/VP on special projects and strategic initiatives
Represents HCP at community and other provider meetings
Over 1 year and up to and including 3 years of experience
Microsoft Office applications skills (Word, Excel)
Knowledge of CPT-4 and ICD-9 coding systems

Provider Relations Project Manager Resume Examples & Samples

Serve as a key resource on complex and/or critical issues
Perform complex conceptual analyses
Review work performed by others and provide recommendations for improvement
Forecast and plan resource requirements
Authorize deviations from standards
May lead functional or segment teams or projects
Provide explanations and information to others on the most complex issues
Motivate and inspire other team members
4+ years of experience in a network management-related role, such as contracting or provider services
3+ years of experience in claims processing, provider data maintenance
Strong knowledge of business processes related to provider experience ie contract loading, provider education, provider reimbursement
Demonstrated success in working with cross functional teams
Excellent communication and presentation skills required including ability to communicate effectively with various levels
Advanced proficiency in MS Office

Provider Relations Consultant Resume Examples & Samples

Communication with external providers, internal stakeholders, and Health Plan CEOs
7 years of provider relations and/or network management experience
7 years of significant healthcare sales experience, particularly in an ambulatory setting
Extensive experience in a healthcare/clinical setting
Keen understanding of key concepts surrounding healthcare reform/transformation
Master’s Degree and/or RN/Clinical Degree or certification
Intermediate level of proficiency with claims/systems processes, contracting and reimbursement methodologies

Provider Relations Administrator Resume Examples & Samples

Excellent analytical and problem-solving capabilities
Requires at least 25-40% local travel to network providers
Coverage area - Philadelphia, PA and surrounding counties
Car & valid driver's license required (mileage reimbursement provided)

Provider Relations Administrator Resume Examples & Samples

Provides guidance on strategic plans, vision, and action plan development for the networks
Verifies and monitors IPA claims payments
Responsible for network development, including physician contracting, network relationships, network communication, physician recruitment, and network partners
Participates in network and company meetings, including physician board of directors, quality management, financial/bonus, operation, committee
May serve as a mentor
Supervise other team members

Provider Relations Administrator Resume Examples & Samples

Manages provider network financials, including monthly action plans, reviews, and verification
Provides guidance on strategic plans, vision, and action plan development for assigned networks
Responsible for network development, including physician contracting, rate negotiations, physician/provider network relationships, physician network communications
Participates in network and company meetings, including physician board of directors, quality management, financial, operations, etc
Responsible for maintaining compliance to CMS and company policies and guidelines
Responsible for execution of key initiatives, such as CMS Star rating program
Supervises others, including but not limited to Network Administrators and Network Operations Representatives
Minimum: Bachelor’s degree or equivalent experience. At least three years related healthcare experience
Preferred: Master’s Degree & IPA experience. Experience in physician relations, managed care, and/or hospitals. Previous management experience

Healthcare Provider Relations Resume Examples & Samples

Analyzes inquiries through use of personal knowledge of the particular functional subject matter. Augments knowledge with reference materials as needed
Provides response and takes appropriate action to resolve. May interact directly with original requestor, advise others on how to respond or escalate to a higher level if needed
Contributes to a shared knowledge database to facilitate response consistency and to document complex issue resolution
Monitors customer inquiries for a specific functional area, tracks progress and resolution of escalated inquiries
Assists less experienced staff in developing appropriate responses
Bachelor’s degree in business management or related field preferred
Experience working with fax machines, computer software and telephone technology
1 year Healthcare experience (claims, enrollment)

Provider Relations Resume Examples & Samples

Test contract performance before operationalizing and perform audits to optimal standards for prevention. May lead/oversee testing and/or auditing of contracts by other associates
Ability to cross train for hospital loads, maintenance tasks (i.e. charge master neutralizations)
Work with Contractor and Provider Consultant to assist with and follow up on routine provider contracts
Ensures initial credentialing, managing unresponsive providers through re credentialing, and resolves discrepancies
Supports with complete system set up for delegation of credentialing and any provider network data needed for other forms of delegation. Manage delegated relationship data: credentialing, UM, claims
Performs administrative duties relative to his/her functional area, supplies pertinent information, maintains records and documentation, and manages logistics for a team. Exhibits professionalism in representing oneself and one's team
Associate’s or Bachelor’s Degree or equivalent years of provider relations experience
Previous provider experience (provider contract, provider relations, or provider service)
Possess a strong attention to detail
Ability to work in a deadline driven environment
Valid driver’s license and/or dependable transportation necessary
Advanced Degree
Prior experience with supporting other complex projects and/or provider networks
Proficiency in MS Access

Provider Relations Project Resume Examples & Samples

Ensures contracts are operationalized from contracting through implementation, leveraging standardized tools and quality processes end to end
Maintains contracts, including making changes and updates using various systems i.e. network add and deletes
Supports and collaborates with Provider Consultant, Contractor, Manager and Director across service operations teams to ensure data integrity and resolve contract intent issues (focused goal of getting it right the first time and elimination of constant rework/retouching of tasks)
Defined point of contact for Contracting and Provider Service (DCAV, PPG, Credentialing, Service Fund) regarding contract administration, data integrity, testing/auditing, maintenance (including annual escalators) attributions and contract clarifications for more complex contracts. This may include path-to-value and value-based contracts
Support team with maintaining HSD tables and network adequacy for Medicare/ Medicaid/ commercial
Assist to coordinate activities or projects of team; such as scheduling meetings, taking minutes, project plan updates, tracking, filing and maintaining project or task log
Associate’s or Bachelor’s Degree and/or a minimum of 5 years of provider relations experience
Demonstrated experience with process documentation
Prior experience working in the insurance industry
Previous experience in claims
Prior contract interpretation experience strongly desired

Healthcare Provider Relations Support Specialist Resume Examples & Samples

Apply basic knowledge of theories, practices and procedures in a function or skill
1+ years of experience in a network management - related role, such as contracting or provider services
In - depth knowledge of Medicare reimbursement methodologies, i.e. Resource Based Relative Value System (RBRVS)
1+ years of experience in fee schedule development using actuarial models
1+ years of experience utilizing financial models and analysis in negotiating rates with providers
At least an intermediate level of knowledge of claims processing systems and guidelines
1+ years of experience in performing network adequacy analysis
Strong interpersonal skills, establishing rapport and working well with others

Provider Relations Coordinator Resume Examples & Samples

Consistently exhibits behavior and communication skills that demonstrate HealthCare Partners’ (HCP) commitment to superior customer service, including quality, care and concern with each and every internal and external customer
Resolves provider issues by interfacing with HCP central departments (Contracting, Eligibility, Claims and Finance)
Reports systemic operational issues to the management team
Coordinates provider outreach for the CCR
Follows up with Payor Contracting department on status of clinicians being added, terminated as well as open / closed panel status based on health plan website and submitted information
Verifies annually the single / dual affiliation status of physicians and follows up when they are not maintaining this status
Serves as a point of contact to central departments for issues related to the network, communicates relevant information from the central departments to the network and provides communications and documents upon request
Makes outreach and follow up phone calls to physician offices related to specific initiatives or meetings (i.e. leadership retreat, RADV audit and AEP meetings)
Researches pay for performance discrepancies
Completes Notice of Changes and Preferred Provider Lists ensuring information on these forms are inputted in IDX, HCP Connect, Visual Cactus and health plan websites
Attends and helps prepare adhoc meetings (i.e. office manger HCC training and lunch and learn)
Takes minutes for specialty JOC meetings
Assists management in developing a quarterly IPA Bulletin containing articles and announcements for the IPA network
Prepares benefit flyers for primary care physicians with health plan ID numbers
Serves as administrative support for Clinician Network Liaisons on days they are not in the office
Collects bios and pictures for website
Responds timely to CSR’s
Delivers incentive and other checks
Responds to and resolves questions or concerns from clinicians or staff in a timely and service oriented manner
Prior experience in a health plan, medical group or IPA setting working with physician networks
Good understanding of HMO systems provider reimbursement mechanisms
Ability to write letters and articles

Provider Relations Manager Resume Examples & Samples

Identifies gaps in the provider network and opportunities for recruitment and forwards contact opportunities to filed representatives for action
Oversees and actively participates in the recruitment of new practitioners and facilities in the geographic area of responsibility including identification, calling, screening, and through attendance at trade shows, symposiums and site visits
Participates in practitioner and facility orientation and training as needed, and resolution of complaints and questions, and preventing disenrollment as necessary
Communicates regularly with network operations management to share information and ensure accurate and timely response to provider
Verbal and written communication skills

Provider Relations & Performance Improvement Resume Examples & Samples

Responsible for the oversight of Provider Relations, Network Management and Performance Improvement Departments at the Georgia Engagement Center
Manages Beacon Health Options local network development, maintenance, and contracting functions according to Beacon Health Options and state and federal regulatory requirements, procedures, applicable accreditation standards and contract requirements
Serves as the primary liaison between local, regional and centralized support functions – which can include provider file maintenance, credentialing and other regional provider relations teams. Identifies credentialing requirements and any non-compliance issues that require enhancements or changes for performance improvement purposes
Manages and oversees relationships with providers and advocates for information and resolution of issues including complaints, grievances, appeals, errors in performance and corrective action plans
Organizes designated committees and work groups and oversees the development of the agenda and presenting quality-related reports in order to improve performance, communication, and operations across the Engagement Center and across the provider network
Responsible for monitoring accreditation readiness for the GA Engagement Center and actively participates at the local and National level to ensure interdepartmental collaboration and coordination in these accreditation efforts
Provides training and technical assistance to credentialing, pre- and post- implementation
Recruits, trains, coaches, evaluates and allocates resources to effectively implement assigned functions for Provider Relations, Network Management, Quality Analysts and Complaints & Grievances positions
Supports the interdisciplinary team in the identification of quality improvement activities (QIA’s) as well as Quality Improvement Projects (QIP). This includes formal written proposals, establishing baseline and ongoing measurement activities that reflect improvement in services provided
Interfaces with external and internal customers when appropriate to ensure ongoing quality improvement activities are in place and monitored for positive outcomes. Works with other departments to ensure collaboration and coordination for specialty and case management programs
Serves as the primary lead in the development, operationalization and evaluation of the Engagement Center's QM portion of the integrated QM/UM work plan. In collaboration with the Directors of Quality and Utilization Management, develops and implements an annual Quality Plan and Evaluation
Coordinates and oversees testing on behalf of the Georgia Engagement Center

Provider Relations Manager Resume Examples & Samples

Recruits new individual and group practitioners and facilities to join the provider network for Beacon Health Options
Ensures demographic information and facility point of contacts (POCs) are accurate by verifying during each provider/facility contact. Forwards all demographic changes, contracting and credentialing inquiries and supporting documentation to the appropriate corporate Provider Relations team
Conducts provider site visits and completes site visit tool to ensure providers are compliant with standards established by the District of Columbia
Performs practitioner and facility orientation and training of office staff on Beacon Health policies and procedures and provides updated training throughout the lifecycle of the provider relationship
Provides administrative and operational support to local team. This will include but not limited to; following up on all return mail; ordering supplies; producing comprehensive reports, deliverables and presentations; some member contact as necessary
Demonstrated abilities to interact with and recruit mental health, substance abuse providers
Excellent written and oral communication skills, flexibility, adaptability, problem solving capability, creativity, initiative, teamwork skills, prioritization skills, public relations and customer services skills required
Ability to travel at least 50% of the time to local provider offices within the DMV

Facility & Group Provider Relations Coordinator Resume Examples & Samples

Research, evaluate and develop responses to requests for changes to contract language, rates and/or contracted services consistent with TRICARE and accreditation requirements. Prepare contracts, amendments and correspondence for facilities and groups, and distribute to PRR manager and/or PRRs
Research facility rates and maintain up-to-date information on TMACs, target and current rates
Oversee the facility database and produce accurate internal reports for facilities, individual providers and groups. Ensure demographic information for providers and facility POCs are accurate in their assigned area. Enter and update notes on all assigned providers
Monitor, facilitate and respond to all voicemails (24-48 hour call back), emails (24-48 hours reply), and CAPs (resolution within 30 days) within required timeframe specified for each. Respond to provider/facility questions via the telephone and email; conduct problem solving and research on issues related to claims denials, authorizations, and credentialing, re-credentialing and general provider/facility inquiries daily.All provider conversations/inquiries must be documented within same day of receipt
Work closely with the Credentialing department to audit all new provider applications, work to secure needed documents for credentialing and re-credentialing upon receipt and/or request from Credentialing upon 3 failed attempts as needed
Maintain databases and produce accurate internal reports for facilities, individual providers and groups. Ensure demographic information and facility POCs are accurate by verifying during each provider/facility contact, to include checking the box in Jenks and adding the date verified.Enter and update notes on all providers in Jenks database. Forward all other demographic changes to the Provider File department
Monitor contract compliance on all assigned providers with goal of 100% compliance in the following areas: 100% claims submitted electronically unless provider meets waiver criteria established; Facility on line authorizations and reviews
Act as a liaison between providers, facilities and other ValueOptions departments to facilitate communication, resolve inquiries and provide education
Overnight travel may be required

MGR Provider Relations Resume Examples & Samples

Daily coordination of workload with staff, performance management and higher level support and guidance with provider relations issues and/or inquiries
Facilitates and participates in staff training for new and existing staff
Assists in the development and implementation of policies and procedures
Assist with the completion of applications and gathering of necessary credentialing documents for practitioners and facilities
Demonstrated ability to interact with and recruit mental health, substance abuse and employee assistance program providers
A demonstrated ability to negotiate financial and contractual language arrangements with facilities that comply with policies, procedures and guidelines for multiple lines of business
Excellent written and oral communication skills, flexibility, adaptability, problem solving capability, creativity, initiate, teamwork skills, prioritization skills, public relations and customer service skills are required

DIR Provider Relations Resume Examples & Samples

Responsible for management, training and supervision of Colorado Credentialing, Document Support, Provider line, Provider recruitment and development, and Provider Relations activities. Ensures properly staffed provider telephone line for provider education and communication, ensuring provider feedback and concerns are properly addressed. Coordinates production of Quarterly Provider Newsletter Communication, updates to the provider website and provider handbook
Ensures all practitioners, groups and facilities are properly credentialed and are processed within required time-frames. Chairs the Local Credentialing Committee and represents the Colorado Service Center on the National Credentialing Committee. Responsible for ensuring overall network adequacy, coordinating network adequacy reviews and associated reports
Ensures standardization of the credentialing and re-credentialing process under corporate and NCQA guidelines. Develops credentialing policies and procedures and ensures compliance with state and federal regulations
Performs site visits; and investigates provider issues to resolution. Attends QOCC meeting, and works collaboratively with clinical, quality and other departments to address quality issues and actively participates in provider monitoring program
Responsible for all Provider deliverables to State and Partners
Responsible for ensuring providers are trained and completion of the provider training plan
Responsible for oversight of the Accountable Care Collaborative provider relations activities and deliverables
Extensive knowledge of managed care environment, network development and network management is required
Excellent communication skills, flexibility, adaptability, problem solving capability, creativity, initiative, teamwork skills, prioritization skills and public relations skills are required
Demonstrated ability to interact and negotiate with mental health, substance abuse, and employee assistance program providers is required
Strong organizational, communication, analytical, problem solving and staff management and budget management skills are required
Ability to manage in a geographically disbursed, complex and changing environment

Senior Provider Relations Data Attestations Advocate Resume Examples & Samples

Undergraduate degree or equivalent experience
4+ years of provider relations and / or provider network experience
Must be willing to travel at least 75% throughout Georgia, North Carolina and South Carolina

Manager, Provider Relations Resume Examples & Samples

Bachelor’s degree preferred or equivalent work experience
4 years’ experience in sales and/or account or vendor management
Background in Human Services or Early Childhood Education preferred
Excellent written and verbal communication skills as well as excellent phone manner
Proficient in basic Microsoft applications (Word, Excel, Outlook) and the Internet to source recruitment leads
Ability to multi-task and prioritize in a fast-paced environment
Strong organizational and time management skills as well as attention to detail

Provider Relations & Contracting Consultant Resume Examples & Samples

Physician, Ancillary and/or LTSS provider relations experience or equivalent
Experience presenting to varied audiences
Proficiency in MS Office applications
Bachelor’s or Master’s Degree in Business, Finance or a related field
Medicaid provider contracting experience

Provider Relations Recruitment & Retention Representative Resume Examples & Samples

Initiate calls to new providers targeting specific program needs and target areas in the State
Recruit providers not currently enrolled in Medicaid
Recruit provider that currently have a low participation
Promote and recruit for THSteps Medical and Dental, CSHCN, Family Planning and other services
Promote and recruit providers to use web based applications such as electronic claim submission and the Provider Enrollment Portal
Deliver presentations for professional organizations and teaching schools
Participate in community activities
Must Reside within the Dallas,Texas area as per the Health and Human Services Commission
High school Diploma
Minimum of 1 year of Medicaid, Medicaid Managed Care and/or Health Plan Managed Care experience
Must reside in or be willing to relocate on your own to the Dallas, TX Area
Minimum of 2 years of Microsoft Office experience
Good financial acumen and financial analysis and diagnosis skills
Excellent leadership, communication (written and oral) and interpersonal skill

Senior Provider Relations Data Attestations Advocate Resume Examples & Samples

Solve moderately complex problems and/or conduct moderately complex analyses
3+ years of experience with provider contracting/provider relations / provider network/provider data
3+ years of experience in the health care industry

Provider Relations Manager Resume Examples & Samples

Supports the provider relations department by managing provider relationships through practitioner and facility orientation, provider inquiries, training, attendance at meetings and participation in resolution of complaints as necessary
Answer practitioners/facility questions regarding enrollment, authorization and Beacon/Medicaid policies and procedures
Participate in the maintenance of provider files. Obtain, process, manage and maintain both hard-copy and computer based provider information necessary for network development and maintenance activities
Provide follow up with practitioners and facilities for the return of completed Provider Data Verification forms. Verify that provider information is current and updated in our database.Respond to providers’ requests for enrollment and authorization information
Research and Problem Resolution: Perform research and problem resolution on issues related to provider complaints, authorizations reported to have been processed incorrectly, provider communications or verification of information as requested.Review and analyze provider information and status though database queries
Excellent written and oral communication skills, flexibility, problem solving ability, creativity, teamwork skills, and prioritization skills required. Strong project management skills are a necessity. Exceptional computer skills, including Microsoft Office applications. Strong organizational, communication, analytical, aggregate and interpret data, present data findings, problem solving, and staff management skills are required

Manager Provider Relations Service Advocacy Resume Examples & Samples

5+ years of provider relations and/or network management experience
Advanced to Expert level of knowledge of claims/systems processes, contracting and reimbursement methodologies
Advanced to Expert level of proficiency with MS Word and Excel
Exceptional presentation, written and verbal communication

Provider Relations Associate Resume Examples & Samples

Answer telephones, take messages and re-direct calls when necessary
Identify provider concerns, questions, and/or complaints and report to PRA Supervisor and other Management, immediately with concerns
Ensure all provider issues are documented in OPM and addressed to appropriate parties
Rectify Provider office concerns to the limits of job skills and authority
Maintain the knowledge base concerning various health plans
Support all calling areas within Scheduling to meet Operations department service levels and KPI’s
Work in all areas with confidence of HIPAA compliance
At least one (1) year work experience as a Scheduler, Field Coordinator, or equivalent position at Altegra Health
At least one (1) year of work experience – customer service or call center
Strong formal physician’s office telephone etiquette
Excellent MS Office Proficiency (Excel, PowerPoint, Word, email)
Ability to navigate through MyODIS
Demonstrated history of reliability and excellent attendance
Strong organization skills and an ability to work independently and under the direction of others
Ability to handle multiple priorities and meet deadlines

Healthcare Provider Relations Manager Resume Examples & Samples

Responsible for the management and direction of the Provider Relations Department in the New England region
Serve as the subject matter expert on the processes, and procedures
Ensures compliance to the contractual obligations as defined in the contract as well as adherence to State and Federal guidelines
Establishes and maintains strong relationships with client, hospitals, providers, provider networks and provider organizations to ensure the flow of information and coordination or services
Ensures the availability of staff, resources and services are effectively and efficiently delivered
Provides mentoring and performance development for direct reports, challenging the team for creative solutions, improvements in customer engagement and service delivery

Provider Relations Specialist Resume Examples & Samples

Responsible for managing the scheduling of provider trainings and events
Assist Provider Relations Manager in developing training materials
Partner with internal departments to identify specific areas of need or underperforming providers and help prioritize training needs
Manage the scheduling of training events
Handles requests for approved changes of address, changes of TIN, and addition of practice sites, entering pertinent data into 4D, FlexCare and CACTUS, which will make the modified data available to the Credentialing Department and the Clinical Department, and will then notify other departments, as applicable, of changes, such as Claims, Accounting, and Network Development. Will notify practitioners if change or addition of address has not been approved, with reasons for same noted in the letter
Creates necessary notifications, adhering to time-sensitive deadlines, upon learning of confirmed terminations of practitioners. 4D and FlexCare are queried for member lists, which are then used to mail-merge approved notification letters to members.4D, FlexCare and CACTUS are updated, which will make the modified data available to the Credentialing Department and the Clinical Department, and will then notify other departments, as applicable, of changes, such as Claims, Accounting, and Network Development
Able to multitask with ease
Moderate skill level in MS Office environment (Outlook, Word, Excel, PowerPoint)
Desire to continually improve problem resolution skills
Team player with an ability to work under pressure

Provider Relations Liaison Resume Examples & Samples

Identifies counselors and develops and maintains positive long term counselor relationships in support of the Military and Family Life Counseling (MFLC) contract. Meets goal of recruiting to assure a network of sufficient size to address all service requests
Assess network needs, analyzes network composition, and makes appropriate recommendations using organization databases, applying appropriate regulatory requirements, and accreditation entity standards. Activities include identification and recruitment of providers to ensure network adequacy standards are met
Maintains tracking systems and manages counselor data to assure that credentialing information is shared in a timely manner between Human Resources, and the Credentialing and Operations departments, and criminal background check vendors
Facilitates complaint resolution of provider complaints, claims, and issues to assuring a timely response and resolution within program expectations
Actively participates in quality improvement activities to increase quality of network recruitment, provider relations and complaint management
Demonstrates expertise of job functions by taking on specialized projects or developing specialized knowledge
Establish and maintain procedures to support OCONUS rotational, surge, on-demand and camp assignment by following government and country requirements
Track necessary information and/or documents to assure all regulatory requirements are met for both CONUS and OCONUS assignments

Senior Provider Relations Coordinator Resume Examples & Samples

Develops contract templates
Drafts language for terms and conditions and ensures that the proper review of contracts is obtained
Responds to requests for information regarding standard contract templates and language
Researches and compares contract rates and maintains files
Develops abstracts of signed agreements
Assists in development, preparation and analysis of RFIs and RFPs
Negotiates and completes letters of agreement under the direction of the Contract Manager
Serves as a liaison and develops strong relationships between KP, contractors and the network providers
Coordinates provider site visits
Prepares agendas and itineraries and participates in conducting presentations as needed
Organizes and facilitates education and orientation sessions for internal and external audiences
Develops provider operations manuals and educational materials
Responds to questions, information requests and problems from providers
Acknowledges and maintains absolute confidentiality of sensitive information
Fills the role of provider advocate
Leads or supports miscellaneous projects as needed
Identifies and resolves billing and payment issues within the context of the contract and regulatory agency guidelines. Identifies, researches, and facilitates resolution of operational issues involving the networks
Responsible for the coordination and ongoing monitoring of the credential process to ensure applications are approved in a timely manner
Conducts research and assists in the coordination and collection of program data
Creates spreadsheets and maintains them for specific information
Creates and oversees the maintenance of an organized system of files for contracts and other documents
Collects and organizes sample agreements for easy reference and use
Minimum of three (3) years of experience in healthcare operations in a managed care environment
Experience with medical billing and coding practices, contract administration and credentialing highly preferred
Experience with network and/or IPA models also preferred

Provider Relations Manager / Trainer Resume Examples & Samples

Under the direction of the Manager, Provider Relations, the incumbent provides support in the areas of facilitating resolution of provider issues or concerns, monitoring the provider network, and ensuring compliance with the terms of the customer contract
Develops, delivers and maintains a comprehensive training program for providers. Maintains a master calendar and schedule of provider meetings/trainings to ensure education and outreach requirements are satisfied in accordance with Provider Relations Communication Plan. Monitors and reports to management the effectiveness of provider training
Trains providers in the use of various provider systems, policies and procedures, system setup and the development of policies and procedures related to system setup
Performs provider outreach to manage ongoing relationship, and is a critical interface link with national network services and network operation staff in the seamless delivery of services to providers including: provider feedback regarding their performance under the terms of the contract and/or custom requirements; identifying and addressing quality of care and service issues, in conjunction with other company departments; responding to provider complaints and questions as they arise; formulating provider report requests and participating in any local and/or national committees/meetings
Contributes to provider newsletters, the provider handbook, and identification of provider mailings, training, and other provider needs based on provider training evaluation results and/or general feedback
Must demonstrate computer competence with Microsoft Office products; possess solid organizational, administrative and communication skills
Excellent written and oral communication skills, flexibility, problem solving ability, creativity, teamwork skills, and prioritization skills required
Must have a strong grasp on current technologies used in a corporate training environment and e-learning
Ability to travel to local and distant provider offices in assigned region by automobile, air, or other means

Associate Director Provider Relations Resume Examples & Samples

Establish leadership, structure, policies and procedures, monitoring and oversight processes to ensure overall outcomes, optimal provider relation experiences
Actively participate in quarterly LTSS Provider Quality Forums and monthly LTSS Provider Review Committee to identify improvement opportunities promptly and providing input for remedial actions as necessary for potential quality of care concerns
Establish quarterly LTSS Provider Quality Forums aimed at informing and training providers on targeted quality measures, using provider-specific score cards
Review of Provider Scorecard and develop annual Provider Quality Performance Plan
Review of annual Provider and Member survey trending results with actionable improvement plan
Identify outlier providers who require technical assistance and use rapid cycle improvement technologies (Plan-Do-Study-Act) to improve their administrative and / or care delivery practices
A current, unrestricted registered nurses license to practice in the state of Massachusetts
Ability to build and maintain relationships is essential
Experience working with providers servicing the Medicaid or LTSS population

Division VP-physician & Provider Relations Resume Examples & Samples

Full employment “life-cycle” responsibilities for selecting, managing, developing, evaluating, and discipliningPhysician & Provider Relations and facility staff to achieve measurable P&PR objectives
Ensures regulatory compliancein all activities
Manages budget and financial matters for Division P&PR
Work with hospital management teams and division management to develop annual organizational and individual hospital Physician & Provider Relations strategic plans
Develop collaborative relationships between division and hospital executives to increase Physician & Provider Relations efforts (growth strategies, service line development , best practice sharing)
Issue Resolution management, including management of data, metrics and dashboards. Create division, market, and hospital Physician & Provider Relations reporting processes used to monitor and summarize division Physician & Provider Relations activities and effectiveness
Track and manage Physician & Provider Relations reports in the database management tool, interpreting data to information for the benefit of the operations leaders
Assist in the development of performance standards (career ladders) and compensation programs for Physician & Provider Relations Representatives
Partner with marketing to develop Physician & Provider Relations materials and strategies to be used by Physician & Provider Relations Representatives
Development and execution of annual Outreach and Telemedicine divisional strategy,including management of AVP, Outreach and Telemedicine
Requires seven to ten years of sales/management experience

Mgr, Provider Relations Resume Examples & Samples

Conducts and directs provider contracting/negotiations and provider servicing
Identifies areas to improve provider service levels
Educates/enhances relationships within the provider community
Assists in developing provider contracting and service
Strategizes for membership growth and retention
Required 3+ years of experience in Management, Supervisory, or Lead/Sr. role with demonstrated leadership ability or program management experience
Advanced Other Financial skills
Advanced Other Knowledge of CMS and state regulations

Coord Provider Relations Resume Examples & Samples

Insures that all newly contracted providers receive an in-service within 30 calendar days from date of fully executed agreement
Performs and documents provider courtesy calls and visits on an on-going basis
Proactive scheduling of on-site visits with providers and maintains a presence in the field
Acts as liaison with other departments to handle inquires, complaints and suggestions from providers
Assists in the research of information necessary for other departments regarding provider issues/operations
Identifies necessary changes and initiates/assists in the development/revisions to functioning provider systems with the appropriate departments
Proactively identifies opportunities to improve the provider’s understanding of proper solutions. Enhance provider satisfaction by answering questions and resolving provider’s issues timely
Provides team approach to provider support when needed
Performs other assigned duties and special project on an as needed basis
Maintains provider in-service log and provider issues and resolution logs
Participates in weekly Provider Relations meeting and monthly Provider Relations and Contracting departmental meetings
Submits completed Provider In-Service Form to V.P., Strategic Operations for approval
Submits timely in-services write-ups
Informs Management on all scheduled provider manual, web module, and other related in-services
Provides Management with feedback from providers with issues and concerns
Responds to routine telephone inquiries and make call backs within the same day or following day
Local travel to provider office’s
Performs other assigned duties / special projects on an as-needed basis
Foster positive interaction and relationships with all internal departments as well as cultivating positive working relationships with external contacts
Bachelor of Arts preferred
Experience with computer programs (Windows, Word, Excel, Access, Mail Merge)
Willingness to learn new tasks and multi-task
Reliable transportation with verification of insurance
Bilingual/Spanish a plus

Senior Provider Relations Manager Resume Examples & Samples

Day to day management of the PRM team statewide
Provide 1:1 and team support as needed
Responsible for oversight of performance and productivity of the PRM team
General oversight of the AHCA compliant process
Ensures the PRM team responds to provider issues, leads problem resolution- both internally and externally to achieve positive outcomes and/or improve workflows
Works with the Quality Improvement Department and Compliance to implement provider focused strategies to ensure contract compliance and oversight
Ensure there are ongoing access and availability activities
Responsible for supporting the PRM team to deliver provider facing trainings in accordance to the AHCA contract
Responsible for the development of a cohesive cross-disciplinary team that can share resources to best address the entire network support for SBU
Manages large scale projects and initiatives to include: improving departmental processes, protocols and efficacies, meet the current business needs and strategic direction, helps to support MCC as a differentiator in the market and better serve our specialized population
Provides orientation, training, education meetings, presentations, and focus groups to improve mutual understanding and enhance working partnerships with providers
Oversees the high denial outreach/non-responder/high appeals initiative in all markets, initiating clinical education meetings with physicians
Provides summary and problem specific feedback information, analysis, action recommendations to service center senior management and relevant functional units regarding provider problems, issues, and general concerns impacting working relationships and company image
Directs, monitors, trends, routine and long-standing provider complaints, claims, contracting, credentialing and other problems requiring regional service center follow-up and resolution
Facilitates immediate resolution of red-flag provider issues that are client, community, legal, or contractual threats with internal personnel as needed
Performs administrative site visits for potential high volume providers on ad-hoc basis

Provider Relations Specialist Resume Examples & Samples

Assist in the basic operations of the Provider Relations Department
Assist with the development and monitoring of provider contracts
Assure the provider documentation is complete and accurate
Communicate any new or updated policy and/or procedure to providers
Collect, clean and ensure the quality of data in the provider data systems
Train others on new systems and serves as provider database helpdesk
Respond to phone calls and emails regarding network providers
Communicate with large retail corporations, vendors and business partners
Update provider website
Coordinate "Ask an Eye Doctor" questions received via website
Notify providers of new groups via mailings, email and phone calls
Prepare reports for providers listing groups in their service area
Request GEO Access reports
Work with other departments, groups, members, and/or agents to resolve provider related issues
Coordinate vision screenings

Provider Relations Functional Analyst Resume Examples & Samples

Demonstrate a strong ability to own objectives, overcome challenges and become a subject matter expert
Perform analysis, planning, development, testing and deployment of assigned projects
Coordinate requirements gathering with internal and external customers while maintaining focus on solutions, deadlines, and professionalism
Research identified issues and reports to management with complete problem definition, evaluation, and proposed solutions
Operate independently and responds rapidly in a complex organizational environment with daily customer interchange
Significant experience using Excel spreadsheets, graphs, charts and word processing functionality
Flexibility and ability to handle a variety of assignments in various stages at the same time
Minimum of 1 year of Medicaid or Managed Care claims or billing experience
Minimum of 2 years of experience with MS Office Suite Word and Outlook in a professional setting
Ability to interact with other department leads and client partners
Operates with a sense of urgency and ownership
Ability to manage multiple cases
Strong analytical and research skills
Strong problem solving abilities
Ability to collect, analyze and document complex business processes

Senior Healthcare Provider Relations Manager Resume Examples & Samples

Expert Knowledge of the Country’s healthcare Insurance market
Expert Knowledge of GCC countries healthcare providers trends and behaviors
Expert Knowledge of the various GCC countries legislations and regulations
Sound Medical Knowledge and claims adjudication
Extensive knowledge of Healthcare Insurance in GCC countries
Expert knowledge of the different Legislations and Regulations in GCC countries
Extensive connection with Healthcare providers in GCC countries
Bachelor Degree in MBBS or Post Graduate studies in Medicine
At least 5 years experience in a similar position

Manager, Provider Relations Miami Resume Examples & Samples

Leads and develops a team of Provider Relations Reps and Provider Ops Coordinators
Assists in developing practices to assist risk partners in managing financial risk
Required 5+ years of experience in Provider Relations or similar background
Preferred Other HMO/PPO background
Intermediate Other Facilitative skills

Provider Relations Manager Resume Examples & Samples

May oversee work activities of other supervisors and direct reports
Adapt departmental plans and priorities to address business and operational challenges
Supervisory, leadership and mentoring experience with a group of direct reports
Knowledge of claims / systems processes, contracting and reimbursement methodologies
Ability to work independently and remain on task
Ability to work effectively and collaboratively with internal business partners
Good organization, planning and follow up skills
Proficiency with MS Word, Excel, Powerpoint and WEBEX technology

Senior Manager, Provider Relations Resume Examples & Samples

Leads and develops a team of Provider Relations Reps
Conducts and directs provider service functions
Actions have impact upon multiple functional areas
Brings resources together in creative ways
Conducts ride-alongs with Reps in the field to develop skills and behaviors and document progress/provide formative feedback through timely and consistent Field Trip Reports
Ensures adherence to contractual obligations and to regulatory requirements
Analyzes the provider network for trending issues involving provider access, satisfaction and process improvement
Assists in developing practices to assist risk partners in managing financial risk. Identifies areas to improve provider service levels
Performs strategic planning for membership growth, retention, and to affect sophisticated or complex provider relationships
Provides training, mentoring and guidance to new managers
Special projects as assigned or directed
Advanced Knowledge of healthcare delivery Strong functional and technical knowledge of healthcare delivery
Advanced Ability to effectively present information and respond to questions from peers and management Presentation skills to communicate business plans in an effective manner
Required Advanced Microsoft PowerPoint
Required Advanced Microsoft Xcelys

Specialist, Provider Relations Resume Examples & Samples

Responds to various inquiries from participating physicians, network staff, hospital staff, and managed care companies
Resolves issues related to credentialing, managed care participation, claims payment, demographic changes, referrals and accessibility
Responds to physician requests, provides updates and resolves issues
Coordinates and implements credentialing activities to assist providers with the completion of applications for network contract offerings; monitors applications and follows-up as needed
Conducts provider and facility credentialing and re-credentialing activities
Communicates with providers to obtain requisite credentialing information to facilitate timely completion and submission of required documents
Facilitates re-credentialing requests and coordinates site visits related to managed care contracts
Prepares and reviews physician membership applications, verifies credentialing materials and enters into database
Communicates with providers regarding Network provider enrollment policies, procedures and contractual obligations
Maintains provider files, as well as availability and contract specific sentinel events
Assist with coordination, education and outreach. Participates in community events
Contributes to network development by working as a key team member to build infrastructure, identify resources, and assist in operational plans. Implements projects and facilitates directives assigned by senior leadership. Collaborates with network staff to facilitate operations
Bachelor’s Degree in Business Administration, Healthcare Administration or related field AND minimum of four (4) years related experience in physician relations or healthcare insurance administration, required
Strong knowledge of National Committee for Quality Assurance and The Joint Commission standards, required
Proficiency in Microsoft applications; Excel, Word and PowerPoint
Excellent interpersonal, oral and written communication skills, required

Manager, Provider Relations Resume Examples & Samples

Ensures contracts are compliant with regulatory requirements and Health System policies
Manages provider credentialing, including Medical Affairs and third party vendor relationship credentialing processes
Develops provider education programs to provide value added benefits for Health System IPA and Health Insurance Company participating providers
Ensures provider database information is accurate and maintained; collaborates with IT to implement modifications, as necessary
Manages and implements staffing requirements. Selects, develops, manages and evaluates direct reports
Ensures implementation and evaluation of operating policies, procedures and processes
Performs related duties, as required
Bachelor’s degree in Business Administration, Customer Service, or related field, required. Master’s Degree, preferred
Minimum of five (5) years progressively responsible work experience to include a minimum of three (3) years experience in managed care, insurance or healthcare environment, required
Strong communication skills, required

Provider Relations Coordinator MSO Resume Examples & Samples

A minimum of 2 years experience in general healthcare, administrative support services, provider and customer service work environment
Equivalent work experience in health care, insurance or credentialing as a substitute to professional degree is acceptable
A bachelor’s degree in health care administration, business administration or related area

100

Provider Relations Resume Examples & Samples

Education: Bachelors Degree or equivalent combination of education, training, and experience may substitute for education requirements
Experience: Experience in provider relations, information systems. Mental health preferred
Other skills & knowledge: Strong PC skills using Microsoft applications including Word, Excel and Access databases. Excellent oral and written communiation skills. Strong analytical, organizational and problem solving skills are needed. Outstanding customer service skills

101

Msla-provider Relations Specialist Resume Examples & Samples

Ensure providers have in depth understanding of MSLA model of care to include, but not limited to, contractual obligations
Participates in provider service expansion to assure network adequacy as needed
All other duties assigned by Management
Minimum 2 years of experience performing customer service in a healthcare setting

102

Manager of Provider Relations Resume Examples & Samples

Maintains close communications with officers of the Piedmont Clinic, CEO/CMO pf the Piedmont Clinic, Executive Director of the Piedmont Clinic, Medical Director of Piedmont Hospital, and Director of Quality Management Department for Piedmont Hospital; keeps the Administration, Medical Director, Executive Director, and physician membership appraised of problems concerning their areas
Maintains records on all physicians, confidential files, bylaws, amendments, and rosters
Updates all databases containing physician information on a daily basis and provides reports as requested for the CEO/CMO, Executive Director, or Piedmont Hospital Medical Director
Responsible for physician mailings and general correspondence
Coordinates and supervises Quality Specialists/Provider Relations staff duties; organizes, implements, and maintains procedures for recording and filing various administrative forms, reports, and confidential medical information
Receives, screens, and assists telephone callers, referring calls to Executive Director or Medical Director when appropriate
Handles special assignments, reports with minimal guidance
Maintains strict confidentiality on all physician and practice matters
Attends required meetings, coordinates and attends in-services and participates in committees as required

103

Provider Relations Manager Resume Examples & Samples

Knowledge of emerging healthcare trends to be able to inform and execute growth strategy
Intellectual inquisitiveness with a desire to create practical/innovative solutions
Ability to cultivate new opportunities by initiating a plan to increase operating margin
Ability to research, understand and explain healthcare services' volume, utilization, market data, and physician referral patterns

104

Mgr, Medicaid Provider Relations / Mgmt Resume Examples & Samples

Coordinates the management and growth of the hospital relations program or ancillary networks; monitors and resolves hospital or ancillary network concerns and issues
Manages advocacy/education process with hospitals and ancillary networks
Develops and implements processes that ensure hospitals and ancillary providers claims are paid accurately, timely, and on first submission
Monitors team activities to assure that staff meets performance standards and is operating effectively and efficiently; resolves escalated claims/operations issues
Evaluates the provider network to ensure appropriate access for membership and develops/executes recruitment plans
Manages the provider complaint and Provider Relations databases; develops and implements action plans regarding provider satisfaction results
Hires, trains, coaches, counsels, and evaluates performance of direct reports
Holds team accountable for provider satisfaction
25% field travel (provider visits with team members, attend conferences, etc.)

105

Provider Relations Associate Resume Examples & Samples

Bachelors Degree and No prior experience required in the Claims area
Resolve technical issues within function or unit
Work with manager to analyze needs, develop and recommend alternatives for improvements to re-pricing process
Work closely with WTP Assist's Assistance and Medical Case Management teams to ensure a cohesive approach to steerage and patient direction within the spirit of our business partnerships
Familiar with a variety of travel health insurance concepts, practices, and procedures
Fundamental knowledge of the insurance industry, claims, and the
3 or more years of claims handling experience in line of business
Experience with US-based medical claims and billing practices
Proven analytical skills gained working with multiple data sets and/or claims types to achieve desired results
Ability to multi-task and adapt to a changing environment
Organization and time management skills
Willingness to embrace the Zurich Basics of Integrity, Sustainability, Customer Centricity, Excellence, and Teamwork
Strong Data Entry Skills

106

Provider Relations Specialist Resume Examples & Samples

Establishes a routine communication cadence with providers, key opinion leaders and teammates in order to communicate initiatives and outcomes
Ensures effective problem resolution to ensure MAPD members have a seamless healthcare experience
Executes analysis and reporting on key initiative metrics while tracking progress relative to goals
Works closes with nursing counterparts and sales leaders to achieve care management and sales goals respectively
Ability to travel up to 50% within the territory of the greater Austin and San Antonio areas as well as across the United States for team and personal development

107

Provider Relations Recruitment & Retention Representative Resume Examples & Samples

Minimum of 1 year of Medicaid, Medicaid Managed Care and or Health Plan Managed Care experience
Proven success in contributing to a team oriented environment
Proven ability to work creatively and analytically in a problem solving environment

108

Division VP of Physician & Provider Relations Resume Examples & Samples

Work with hospital management teams and division management to develop annual organizational and individual hospital sales plans
Create division, market, and hospital sales reporting processes used to monitor and summarize division sales activities and effectiveness
Meet with targeted physicians as needed, but at least quarterly for retention of current business and development of new business
Assist in the development of performance standards and compensation programs for Sales Representatives
Monitor and manage ongoing training and development of all Sales Representatives
Partner with marketing to develop sales materials and strategies to be used by Sales Representatives
Establishing Strategic Direction - Ability to establish and commit to a long-range goal or vision after analyzing factual information and assumptions

109

Provider Relations Functional Analyst Resume Examples & Samples

Significant experience using Excel spreadsheets, graphs, charts, Access, Visio, Crystal Reporting, Foxfire reporting and word processing functionality
Analyze data to predict outcomes, process map and implement various projects
Develop and maintain reports across multiple platforms
Minimum of 1 year of experience generating reports using MS excel
Minimum of 1 year of data analysis experience

110

Provider Relations Billing & Education Representative Resume Examples & Samples

Conduct face to face scheduled and unscheduled visits within the provider community
Maintain a working knowledge of Medicaid program and policy, online provider resources, and internal processes and technological applications
Provide on demand education regarding policies and procedures related to Texas Medicaid Provider billing and enrollment
Coordinate and conduct orientations and training for newly enrolled, as well as established, providers
Research provider claims and Medicaid policy
Present policy based educational information including but not limited to, webinars, workshops, and provider and association/expert forums
Document of all provider/external stakeholder communications
Independent management of local territory through utilizing internal job aids and resources
Meet all contractual obligations while establishing and maintaining positive interpersonal relations among stakeholders
Develop interpersonal relationships with peers and workgroups while working remotely
Participate in team training and workgroups in addition to individual territory responsibilities
Minimum of 2 years of healthcare, project support and/or management experience

111

Provider Relations Summer Intern Resume Examples & Samples

Pursuing a Bachelor's degree from an accredited college/university
Healthcare background preferred, not required
Advanced Excel, Access, Power Point required
SQL or SAS and Tableau experience preferred
Past experience building and updating dashboards required
Strong analytical skills and ability to make recommendations required

112

Senior Provider Relations Coord Resume Examples & Samples

Audits: Accountable for the preparation & submission of specific audit documents, participates in regional/national compliance audits & initiatives
Develops recommendations for Corrective Action Plans (CAP), based on review findings & works w/ the various departmental managers & Regional stakeholders to implement the CAP
Contracts: Recommends & drafts language for terms & conditions & ensures that the proper review of contracts is obtained
Responds to requests for information regarding standard contract templates & language
Researches & compares contract rates & services
Develops abstracts of signed agreements, independently & in consultation w/ the Contracting department
Interprets contract terms & translates the terms into KP operations, provider operations & claims operations
Assists in development, preparation & analysis of Request for Information ("RFI") & Request for Proposal (RFP)
In consultation w/ the Contracting department, may negotiate & complete Letters of Agreement &/or settlements
Customer Relations: Manages & develops strong relationships between KP, contractors & the network providers
Oversees preparation of agendas and itineraries, develops presentation & education materials
Organizes & facilitates education & orientation sessions for internal & external audiences
Advocates & serves as liaison for the contracted Provider Network
Establishes & maintains account profiles for each contracted provider that includes key metrics, site visit schedules, provider manual maintenances log, claims projects & disputes (informal and formal)
Provider Manual: Develops provider operations manuals & educational materials
Because the Provider Manual is a legally binding document, reviewing all content w/ KP legal
Monitors, tracks & resolves questions, information requests & problems from providers
Acknowledges & maintains absolute confidentiality of proprietary information
Training: Develops the educational materials that support training on the Provider Manual for internal & external audiences
Identifies need for, creates & trains internal & external audiences on other topics that impact provider network administration
Project Management: Initiates &/or supports departmental projects as needed
This includes presenting business cases for projects that might require cross-departmental support & seeking sponsorship for projects requiring resources & executive leadership support
Trouble Shooting & Problem Solving: Identifies & resolves billing & payment issues within the context of the contract & regulatory agency guidelines
Identifies, researches & facilitates resolution of operational issues involving the networks
Quality & Credentialing: Responsible for the coordination, collection & submission of credentialing documents to the Regional Credentials Committee (RCC)
Accountable for the ongoing monitoring of the credential process to ensure applications are approved in a timely manner, including presentation of credentialing information to the Regional Credentialing Committee & taking the lead in coordinating provider site visits
Accountable for working directly w/ the medical center & regional quality leadership on contract provisions related to quality & for representing the department at regional & medical center quality meetings for non-KFH providers
Metrics & Reports: Develops & maintains reports on key metrics for network administration
Provides monthly reports to the Manager, Provider Relations on all provider account profiles & a report that aggregates the metrics for all assigned providers i.e., the assigned provider portfolio
Minimum of three (3) to five (5) years of experience in health care operations in a managed care environment
Experience w/ medical billing & coding practices, contract administration & credentialing highly preferred
Experience w/ network and/or IPA models also preferred
Bachelor's degree or equivalent experience in health care administration, finance, business or related field
Competent computer skills including MS Office required
HTML programming, Web site development skills & familiarity w/ KP database systems desirable
Must have strong oral & written communication skills
Strong analytical & organizational skills also required
Excellent customer service skills w/ the ability to make independent judgments, handle multiple projects simultaneously, adapt to shifting priorities & utilize time management skills to meet deadlines
Team player who works well in a fast paced environment
Ability to work w/ a diverse group of people, including physicians, support staff, coworkers & management
Is tactful & diplomatic
Demonstrated ability to research issues & bring about resolution either directly or w/ the assistance of others
Six Sigma lean process, project management experience and/or qualifications, e.g., professional presentations using WebEx, account management, advanced Microsoft Excel, intermediate to advanced Visio, financial analysis of expected verses actual claims payment, account management preferred
Clinical qualifications in addition to the other preferred qualifications will be considered strength
Some travel within Southern California service area and/or statewide may be required
Must be able to work in a Labor Management Partnership

113

Provider Relations Manager Resume Examples & Samples

Minimum of five years’ experience with PBM provider network contract administration required
Minimum of three years’ experience with NCPDP and X12 standards related to PBM
Minimum of three years’ experience with project management

114

Provider Relations Coordinator Resume Examples & Samples

High School graduate with advanced training in healthcare, business, or a related field required
Five (5) years of operational experience in a managed care organization specifically in the area of provider network management to include provider orientation, ongoing educational activities, problem resolution and provider communications required
Incumbent must demonstrate proven success in establishing and maintaining positive working relationships with health care providers and their staffs
Working knowledge of HMO business operations specifically the functions of utilization management, member services, claims, credentialing and benefit plan interpretation
Experience preparing and presenting information to individuals and groups
Must be attentive to detail, have excellent organizational, problem solving, verbal and written skills
Must be able to work independently and actively participate as an integrated team member
Experience with governmental managed care programs desire

115

Provider Relations Research Analyst Resume Examples & Samples

Researches issues of moderate scope where analysis of situations or data requires review of a variety of factors
Exercises judgment within defined procedures and practices to determine appropriate action
Provides written documentation of research findings and may reach out to other departments to report trends
Contacts state agencies, providers and clients with research resolution results
Maintains complete and accurate records of all research activities and provider contacts
Interacts with all levels of management and clients effectively
Meets established productivity guidelines
Minimum of 2 years of customer service, healthcare marketing and/or outreach experience
Minimum of 1 year of Medicaid, Managed Care, or Health Insurance experience
High School diploma / GED
Ability to work in a fast paced, team oriented environment
Strong time management skills with the ability to support multiple tasks simultaneously
High level of professionalism and confidentiality
Ability to utilize sound judgment and independent thinking
Ability to work effectively with all levels of administrative and professional personnel and to creatively anticipate and solve problems
Maintain confidentiality and comply with Health Insurance Portability and Accountability Act HIPAA
Ability to establish and maintain positive and effective work relationships with coworkers, clients, and providers

116

VP, Provider Relations Resume Examples & Samples

Develop and execute strategies for a function or discipline that span a large business unit or multiple markets/sites
Product, service or process decisions are most likely to impact multiple functions and/or customer accounts, both internal and external
Provide leadership for and is accountable for the performance and direction of provider service and advocacy through multiple layers of senior and professional staff
Direct others to resolve business problems that affect multiple functions or disciplines
Represent UHN at critical JOC, Provider Advisory meetings and State Representative Meetings
Location can be Louisiana (Baton Rouge, Metairie), Mississippi (Jackson) or Alabama (Birmingham)
8+ years of provider relations and/or network management experience
5+ years proven ability to enhance provider satisfaction and internal processes
Expert level of knowledge of claims/systems processes, contracting and reimbursement methodologies
8+ years of experience with Medicare and Medicaid regulations
Expert level of proficiency with MS Word, Excel, and Access
Experience working with large provider groups and/or state representative
Excellent organization and planning skills
Undergraduate or higher level degree

117

Dir, Provider Relations Resume Examples & Samples

Directs network operations related Magellan information systems to ensure alignment with contractual requirements and achieves goals established by the organization
Systemic/Policy Changes: Develop, implement, and maintain structures for timely and thorough review of contract changes and policy changes for impact on system set up for Magellan and the provider network in coordination with other CMC leaders. Ensures appropriate communication/education with provider network regarding contractual/policy/system changes which require provider preparation and planning
Proactive Provider Orientation, Education and Tool Development: Manages/provides oversight to team of provider relations liaisons, supervisors, and Manager of Provider Operations to provide orientation, training, education, presentations, and focus groups to improve mutual understanding and enhance working partnerships with providers. Provide direction in proactive development/enhancement of provider-friendly tools and resources
Review and approval of provider notices and communications to ensure accuracy of information as well as focus on transparency and collaboration with providers
Provide summary and problem specific feedback information, analysis, action recommendations to CMC senior management and relevant functional units regarding provider problems, issues, and general concerns impacting working relationships with providers

118

Provider Relations Manager Resume Examples & Samples

Clinical, healthcare, or related experience
Minimum two (2) years experience in outside sales, marketing or related experience
Experience in healthcare related lead generation, preferred
Experience in post acute or acute organization preferred
Must be capable of maintaining regular attendance

119

Coord Provider Relations Resume Examples & Samples

Foster positive interaction and relationships with all internal departments as well as cultivating
Positive working relationships with external contacts
California Drivers License

120

RN, Provider Relations Manager Resume Examples & Samples

Assist in the design, development and delivery of innovative training initiatives/materials
Make training design recommendations based on observations and feedback received
Establish tools to conduct post-training analysis to determine effectiveness
Build relationships with management team to ensure training and resource materials are supportive of their business needs
Track, report, and monitor the training initiatives in local region
Responsible for Network Services responsibilities
Field and follow-up on PR complaints in a time sensitive manner
Responsible for oversight of Home Health including assisting with authorizations and care conferences
And all other duties assigned by the manager and/or supervisor
Organizational skills with the ability to handle multiple tasks and/or projects at one time
Customer service skills with the ability to interact professionally and effectively with providers, third party payers, physicians, and staff from all departments within and outside the Company
Analytical and interpretation skills including departmental, utilization, financial and operations data
Creative thinking skills with the ability to ask the needed bigger-picture questions that lead to process and team improvements
Leadership skills with the ability to empower, engage, motivate, evaluate and manage team members individually and as a group
Minimum 2 years clinical experience in hospital setting
Experience in group presentations/training
Knowledge of ICD and CPT coding
Knowledge of Medicare products and regulations, especially for the HMO population
Personal computer experience should include working with Microsoft Word, Excel, PowerPoint and Outlook at the intermediate level at a minimum

121

External Provider Relations Recruiter Michigan Remote Resume Examples & Samples

Expand Guardian’s Dental Network by strategically focusing efforts on Access
Use effective sales techniques to successfully contract providers to Guardian’s dental networks within assigned territories
Possess extensive knowledge of all of Guardian’s dental products including value to the provider, member, and client
Share and utilize best practices
Achieves results, takes initiative, values people, learns and adapts, does the right thing, communicates effectively, demonstrates business knowledge, puts customer first, improves and innovates, uses sound judgment
Excellent written and verbal communication and negotiation skills. Proficient in Excel, Word and Access
Ability to analyze situations and strategize
Thorough knowledge of Dental products
8 years of Dental Recruitment experience preferred
Proven track record of successfully and consistently meeting and/or exceeding goals required

122

Dental Provider Relations Specialist Resume Examples & Samples

Bachelor’s degree in Dental Hygiene, Healthcare/Business Administration, Marketing, Management, or related field plus 4 years work experience in the health/dental care industry with specific experience/focus in health care provider relations, contracting, negotiations, claims processing and/or customer service or dental offices (clinical or management) OR equivalent combination of education and related health/dental care work experience
In-depth knowledge and understanding of the dental provider community, principles of healthcare delivery systems, and an understanding of dental reimbursement methodologies
Broad knowledge of the company’s policies, procedures, product lines and benefit structures
Familiarity and background with company’s dental provider networks. Familiarity with physicians, hospitals, clinics, laboratories, skilled nursing facilities and other institutional and individual providers
In-depth familiarity and understanding of company’s internal systems and infrastructure (including claims systems, provider file systems, reimbursement systems, and member benefit systems) to effectively operationalize dental contractual provisions and requirements
Will be required to travel within a designated geographical area
Possess excellent PC skills to include but not limited to word processing, spreadsheet software such as Microsoft Word and Excel as well as presentation software development skills
Excellent and demonstrated project management, time management and organizational skills. Must have proven ability to organize and manage a broad range of multiple technical and administrative projects and issues simultaneously
Excellent oral and written communication skills to effectively interface and communicate with a broad array of internal and external contacts and must possess and demonstrate excellent customer service skills
Demonstrated ability to take initiative and be successful working independently

123

Provider Relations Analyst Resume Examples & Samples

Must be UNET Proficient
3+ years of experience working in a medical related field
3+ years of experience working with adjustments or claims processing
UNET proficiency (preferably related to claims processing or adjustments)
1+ years of Customer Service Experience
1+ years of experience with root cause analysis
Managed Care or Medical Insurance experience
Experience in a provider support role
Experience in the Medicare and Retirement line of business
Current SME in adjustment or claims processing role

124

Provider Relations Communications Specialist Resume Examples & Samples

Assist with managing, developing, and maintaining marketing literature and communications designed to project a favorable image of Beacon Health Options (Beacon) to internal and external stakeholders
Maintain content and appearance of Beacon website materials, using standard content management system
Design, edit, format, and produce communications on tight deadlines. This includes ensuring quality, accuracy, and timely distribution
Write and edit content for presentations, collateral, website, articles, and other communications. This includes consulting with internal clients to develop materials that establish or maintain relationships with parties important to Beacon (i.e. local and state licensing organizations)
Execute basic design tasks such as newsletter layout, PowerPoint slide maintenance, and document formatting
Build solid vertical relationships, establishing a consultative role with many internal divisions to create effective communications
Create and execute communication strategies and plans for defined results
Responsible for writing, analyzing, and distributing reports; developing presentations; responding to contract needs; assisting with communications related to implementations; writing and maintaining complex documents
Communicate regularly with internal and external stakeholders using email, webinar, and in-person meetings to educate and collaborate on projects
Some travel may be necessary
Perform other duties as necessary for Marketing and Communications
Solid knowledge of design and writing principles
Solid organizational, administrative, analytical, written, presentation, and communication skills
Familiarity with software such as Microsoft Office Suite and Office 365 (Outlook, Project, Visio, Word, Excel, PowerPoint, SharePoint), Cisco WebEx, Adobe Creative Cloud (InDesign, Acrobat X Pro), WordPress, and Constant Contact is preferred
Solid knowledge of web-based content management systems
Ability to manager and lead
Solid proofreading and writing skills
Editing experience in an online environment

125

Director Provider Relations Resume Examples & Samples

Sets goals for their area and works closely with Managers/Representatives to drive performance and to ensure provider satisfaction metrics are met or exceeded
Conducts field rides with Provider Relations Representatives to gauge their performance and provide coaching and development in order to improve the business results
Plans, conducts and directs provider contracting/negotiations and provider servicing
Develops practices to assist risk partners in managing financial risk
Performs data analysis and develops specific actions to manage medical cost trends
Plans, provides resources and directs activities, network development, provider contracting/negotiation and provider service functions
Develops provider contracting and service strategies and ensures maximum efficiencies in the utilization of human and financial resources
Strategizes for membership growth, retention, and to affect sophisticated or complex provider relationships
Maintains compliance for State and CMS audits
Required 7+ years of experience in provider relations or similar background
Intermediate Demonstrated leadership skills
Advanced Demonstrated analytical skills
Intermediate Other Provides proactive approach and support to emerging business activities established to remain competitive in the marketplace
Intermediate Other Ability to convert related activities into a comprehensive work plan

126

Provider Relations Manager, Registered Nurse Resume Examples & Samples

Assist in the delivery of innovative training initiatives/materials
Provide recommendations based on observations and feedback received
Establish and maintain strong communication channels and relationships with field staff
Maintain confidentiality relative to organizational strategies, objectives, and provider reports
Assure that all responsibilities are performed consistently with the deliberate plans of the organization
Field and follow-up on Provider Relations complaints in a timely manner and follow up on designee assignments
Review claims to identify root cause and create cases to facilitate claims activities
Assist in contracting for the market
Complies with all guidelines established by the Centers for Medicare and Medicaid (CMS) and guidelines set forth by other regulatory agencies, where applicable, and defined in the Universal American Corporate and department policies
Assist in the oversight of Home Health including assisting with authorizations and care conferences
Professional verbal and written communication skills, with the ability to clearly articulate thoughts and ideas
Decision-making skills with the ability to investigate and weigh alternatives and select the course of action that provides the greatest benefit to the organization
Time management skills with the ability to prioritize and schedule daily activities for the most efficient use of time
Problem solving skills with the ability to look for root causes and implementable, workable solutions
Interpersonal skills with the ability to work in a fast-paced environment and participate as an independent contributor with little supervision or as an active team member depending on the situation and needs
Must have a track record of producing work that is highly accurate, demonstrates attention to detail, and reflects well on the organization
RN with current state appropriate licensure with at least five years' nursing experience in an acute or managed care setting (unrestricted clinical license)
Minimum Associate's degree required
Minimum 5 years previous supervisory experience that includes Quality Assurance, Care Coordination or Utilization Management experience
Maintains a valid driver's license for any required facility on-site and home visits
Experience in identifying organizational needs and developing programs to address those needs
Successful record of accomplishment in working independently and in a team environment

127

Parent & Provider Relations Manager Resume Examples & Samples

Holding final responsibility for parent and provider satisfaction relating to all tuition assistance policies and procedures as well as the data and enrollment system
Monitoring the development, rollout, and performance of the third-party-developed data and enrollment system and managing the relationship with the vendor developing and maintaining the system
Participate in hiring of team members and managing team performance
Ensuring successful operation of the tuition assistance process, including confirming provider and child eligibility and contracting
Ensuring providers seeking tuition assistance satisfy compliance requirements
Ensuring the team handles low daily volume of incoming calls from families and preschools in a professional, customer-friendly, and timely manner
Ensuring team members make outbound calls to families and preschools to follow up on pending attendance records/applications
Handling issues that are escalated by the team
Interacting with program partners on a regular basis either in person, via phone, or via email
Ensuring team members properly assist parents and preschools in multiple phases of the application and enrollment process in a timely manner
Coordinating with the Quality Improvement Manager to smoothly transition providers from 2 stars to 3 stars on the state SUTQ rating scale
Coordinating with the Finance Manager to collect data for reports to the State and coordinating with the third-party program Evaluator
Serving on Cost of Quality – Wages committee, a group convened to develop the policies that will govern CPP funding that will go towards ensuring preschool providers receive a living wage
Bachelor’s degree; ideal candidates will have a degree relating to early childhood education or a related field
At least five years previous experience in the education space, ideally in early learning. Strong candidates will have familiarity with the Ohio Step Up to Quality (SUTQ) rating scale
A minimum of one (1) year experience in, bookkeeping, accounts payable, and/or eligibility determination
Cultural fluency and ability to interact with people of all backgrounds; candidates bilingual in English and Spanish strongly preferred
Comfort in interacting with data systems
Previous management or supervisory experience
Experience handling sensitive and confidential inquiries
Experience managing and working with a customer relationship management (CRM) systems
Ability to implement and manage multiple projects at one time
Ability to field inquiries and manage customer relations with a high level of customer service
Strong written and communication skills and detail-orientation
Enthusiasm for the CPP mission of expanding quality preschool coverage and growing the pipeline of dedicated and skilled preschool educators
Extensive Experience in Microsoft Office programs (Word, Excel, PowerPoint)

128

Provider Relations & Network Manager Medigold Corporate Service Center Resume Examples & Samples

Recruit providers to build a cost effective and high quality provider network within MediGold guidelines
Serve as the MediGold point of contact within the Provider network
Act as the MediGold Subject Matter Expert and brand ambassador
Addresses customer complaints by directly handling the issue, working with the correct department(s) to resolve, or escalating as required
Engage Providers to develop, coordinate, and lead training and distribution of materials
Proactively drive communications with Providers via telephone/email and onsite visits
Collaborates with the Director - Provider Contracting and Network Development to develop communication goals, strategies, and plans
Negotiates provider contracts within MediGold guidelines and financial standards
Collaborates with the Managers of Member and Provider Communications to oversee the completion of all provider communication content and materials
Manages and works with other internal partners to facilitate provider Joint Operating Committee (JOC) Meetings
Develops, implements, and manages policies, and procedures as assigned
Assists Director and/or Sr. Director with the Medical Delivery Systems budget
Manages successful implementation of provider contracts, including interpretation of payment and reimbursement terms
Bachelor's degree in Healthcare Administration, Finance, related field or equivalent experience
Minimum five years of experience with a Health Plan or Health Provider. Prior contracting and network development experience highly preferred
Knowledge of physician claims coding and Provider reimbursement payment methodologies. Ability to interpret Provider contracts
Establish and maintain relationships with Providers to ensure quality and satisfaction of services provided
Capacity to address complex problems including claims issues and customer service complaints; work with other departments to achieve resolution of the issues
Demonstrated ability to identify areas of opportunity within Provider networks for improving overall efficiency and quality

129

Provider Relations Recruitment & Retention Representative Resume Examples & Samples

Familiarity with all Microsoft Office programs with experience using Outlook task management tools
Working knowledge of Medicaid, Medicaid Manage Care and or Health Plan Managed Care
Excellent communication skills verbal and written
Ability to self monitor
Excellent bilingual public speaking skills
Strong work ethic and solid judgment
Organizational, multi tasking, and time management skills
Proven success in contributing to an individual and team oriented environment
Excellent leadership, communication written and oral and interpersonal skill
Must be able to travel within the designated region, as well as to the central Accenture location in Austin as requested by Leadership
Independent thinking, problem resolution with strong organizational capabilities
Proven ability to exercises judgment within defined procedures and practices to determine appropriate action

130

Provider Relations Recruitment & Retention Representative Resume Examples & Samples

Minimum of 1 year Medicaid, Medicaid Managed Care and or Health Plan Managed Care experience
Minimum of 1 year healthcare experience
Excellent public speaking skills

131

Provider Relations Resume Examples & Samples

Telephonic outreach to providers, conveying key program messaging
Meets compliance criteria following established guidelines
Achieves successful completion of visit based upon rigorous time frames
Thoroughly documents and follows up as applicable
Communicates to designated customers following protocol
Schedules travel to achieve maximum efficiency based upon assigned visits
Represents Accenture professionally and creates a positive reflection to providers Meets established quality metrics
Collaborates with leadership and team to meet established goals and maximize efficiencies
Assists with other projects as assigned
Minimum 1 year of healthcare experience
Minimum 2 years’ Microsoft Office
Working knowledge of Medicaid, Medicaid Managed Care and or Health Plan Managed Care
Excellent communication skills verbal and written Microsoft Products
Ability to self-monitor, follow directions and meet deadlines

132

Director Provider Relations Resume Examples & Samples

1) Lead the development and management of provider relationships throughout the state, including both regionally important providers as well as broad network of independent clinics and hospitals
2) Direct a statewide staff of contract managers. Lead staff in developing and maintaining positive operational relationships with the broad network of providers. Consult with leadership in other divisions to assure that resources are prioritized to meet provider and corporate needs
3) Consult with the Director of Provider Contracting to assist in the development and execution of negotiation plans. Lead and/or assist with negotiations as agreed upon with the Director of Contracting
4) Represent the Network Management division on management level committees and work teams to assist in the development of networks and products that meet customer requirements
5) Provide leadership and coaching to staff on strategy, best practices and professional development

133

Manager, Provider Relations Resume Examples & Samples

Performs special projects as assigned or directed
A Bachelor's Degree in a related field preferred or equivalent work experience is required
5+ years of experience in Provider Relations or similar background required
3+ years of experience in Management, Supervisory, or Lead/Sr. role with demonstrated leadership ability or program management experience required
HMO/PPO background preferred
Intermediate - Ability to lead/manage others
Advanced - Demonstrated interpersonal/verbal communication skills
Advanced - Knowledge of healthcare delivery
Advanced - Functional and technical knowledge of healthcare delivery
Advanced - Ability to influence internal and external constituents
Advanced - Demonstrated analytical skills
Intermediate - Facilitative skills
Advanced - Financial skills
Advanced - Knowledge of CMS and state regulations
Advanced proficiency in Microsoft Outlook, Word, and Excel required

134

Physician & Provider Relations Sales Specialist Resume Examples & Samples

In collaboration with division and/or market clinical and business development leaders, evaluate, analyze, and interpret market utilization data for market facilities' service line, ensuring that sales priorities are identified in line with the vision and strategic goals of the Service Line
In collaboration with division and/or market CEO's, evaluate, analyze, and interpret current physician referral patterns and trends for market facilities' service line, ensuring that sales resources are optimized
Provide thorough explanation of service line attributes, processes, and outcomes to consumer, physician, and market facility groups/individuals as needed
Evaluate, analyze, and interpret financial margins for existing market facilities' service line
In collaboration with division and/or market physician services, facility leaders, medical staff leadership and facility physician relations teams develop sales and retention strategies for target markets and facility service line
Develop goals and timelines for closing new or enhanced physician referrals
Present and gain support and commitment from market leaders, facility leaders, related medical staff leadership, and Outpatient Service Group Leaders for the service line market vision and sales plans
Complete face-to-face sales meetings with physicians and practice managers, ensuring that a thorough understanding is gained regarding the physicians' desires and needs
Complete follow-up meetings with physicians, practice managers, and/or other providers as needed to close new or additional business, ensuring that internal and external obstacles to business growth and retention are identified and minimized or eliminated
Continuously modify sales and retention strategies and plans to ensure optimal business outcomes and "win-win" results for physicians and company market providers for the service line
Ability to access, understand, and explain physician referral patterns
Ability to demonstrate comprehensive knowledge of sales strategies and techniques
Ability to verbally articulate service line and product attributes
Ability to actively listen to physician and practice needs for hospital inpatient and outpatient services

135

Provider Relations Account Executive Resume Examples & Samples

High School Diploma/Equivalency Required
Bachelor’s Degree in a related major (e.g., Business, Healthcare Administration, etc.)
One to three years experience in a Provider Services position working with providers
Three to five years experience in the managed care/health insurance industry
Demonstrated strength in working independently, establishing influential relationships internally and externally, meeting and training facilitation skills, priority setting and problem solving skills

136

Provider Relations Specialist Resume Examples & Samples

Manages the MCO claims dispute and resolution process for multi-specialty network of providers. This requires an in-depth knowledge and understanding of DPHO’s 25+ MCO contracts
Proactively establishes and maintains positive working relationships with MCO executives, DPHO physicians, and DPHO practice managers
Analyzes MCO contracts to determine if the payor and provider are in compliance with applicable contract terms
Mediates between the MCO and the physician practice to resolve the applicable issue in conformance with the applicable contract language, including negotiation of settlement arrangements as necessary. This requires creative, independent problem solving skills
Identifies and facilitates resolution of underlying root problems. This requires an in-depth understanding of the claims submission and payment process as it applies to a multitude of specialties and services
Tracks all claim/loading issues from inception to resolution in a format that is viewable by other DPHO team members. Establishes a system and process to confirm that all issues are completely resolved to the satisfaction of all parties before closing the case
Analyzes claims problem trends to determine if modifications need to be made to underlying MCO contracts to proactively address and resolve such trends
Works closely with the Sr. Data Analyst to identify and resolve internal issues contributing to provider claims disputes. Interacts with practice staff to gather and verify required data management information
Provides timely assistance to DPHO providers on all other matters related to DPHO physician participation in DPHO MCO contracts
Orchestrates and completes the contract participation process for all new MCO contracts per the terms of DPHO’s provider agreements and the terms of the applicable MCO agreement
Completes annual data integrity validation process with each payor to ensure DPHO providers are properly represented on payors’ public directory sites. Facilitates data clean up and process improvement initiatives with payors
Completes quarterly data integrity validation process with each DPHO practice to confirm accuracy of data in DPHO’s databases
Attends DPHO managed care meetings, practice meetings, and payor orientations as appropriate
Participates in continuous quality improvement activities and teams
Participates in supporting the organization’s vision, mission and values and adheres to DeKalb Medical Standards of Behavior
Performs other duties as assigned to meet the goals and objectives of DeKalb PHO and DeKalb Medical
Associate Degree or equivalent combination of education and relevant experience required or Bachelor’s degree preferred
Three to five years’ provider relations experience with managed care company, provider organization, or physician practice is required
Knowledge of insurance claims and settlement processes is required
Familiarity with medical billing and coding is required

137

Director, Provider Relations Resume Examples & Samples

Professional growth opportunity
Ability to positively impact provider and member experiences with ABH-MI
Ability to work with cross functional teams and varied projects beyond day to day servicing model

138

Provider Relations Manager Resume Examples & Samples

Assumes role in researching provider complaints and issues, collaborates with staff from various internal operations areas to determine root causes. Remedies problems, being on point to communicate with providers throughout the course of problem resolution
Takes the front-line in establishing and maintaining strong communications with providers
Develops and maintains strategic and tactical approaches to relating to high-impact providers in the network that will distinguish the company in the industry and result in peak provider satisfaction and network stability
Establishes and maintains optimal communication channels with client provider relations and account management to foster confidence in the company`s abilities to rapidly resolve provider issues
Identifies opportunities for promoting broader use of web services and proactively communicates with providers not taking full advantage of these services to understand why
Identifies providers not availing themselves of EDI and EFT, and proactively communicates with them to transition them to these platforms
Conducts telephonic, web-based and onsite training sessions (individual and group) for new network participants (rendering providers) and for ordering providers during new client implementation phases
Conducts training sessions for clients? provider relations and call center staff so as to equip them with the background knowledge of processes to assist in their ongoing training of their network providers
Routinely monitors provider performance to target and perform remedial training sessions based upon area of need (e.g., authorization processes, claims submissions, etc.)

139

Provider Relations Intermediate Coordinator Resume Examples & Samples

Conduct data driven operations meetings with assigned network of providers which includes IPA/medical groups, PPO providers/provider groups and Hospitals; Ability to drive critical discussions with assigned network of providers to deliver established quantifiable goals and targets
Execute provider relationships and performance strategies
Support assigned provider book of business in a customer-focused, effective and efficient manner
Organizes and follows up with internal functional areas to ensure resolution of claims and service problems
External facing position that develops and maintains deep and long lasting relationships with providers
Customize education and trainings to meet the needs of providers as well as effectively delivering it in group settings
Coordinate escalated claim disputes and all necessary research timely and effectively which may require some reliance on their manager and senior level peers in setting action plans to analyze and resolve root cause issues
Coordinate and monitor provider’s compliance with regulatory requirements
Work closely with their assigned IPA/medical groups to ensure compliance with Access & Availability requirements
Complete Transition & Disengagement Reports required by the Department of Managed Health Care when IPA/medical groups or Hospitals submit termination notices
Ability to lead ad-hoc projects/assignments and actively participate in all internal and external meetings
The job requires moderate level of autonomy in decision making since PRC’s main customers (providers) need to rely on the PRC’s for answers to issues that need immediate resolution

140

Provider Relations Experience Manager Resume Examples & Samples

3-5 years of experience in provider relations or health care
Bachelor’s degree preferred, or equivalent work experience
Strong relationship-building and account management skills
Understanding of medical insurance products and associated provider issues
Demonstrated ability to develop strong working relationships with matrix partners in organizations; ability to leverage matrix resources to drive deliverables
Demonstrated strong oral, written, interpersonal, presentation, analytical, and persuasive skills
Demonstrated planning/organizational skills; ability to plan for both the long and short term; ability to work on many issues at once and to prioritize work
Ability to use PC software and multiple CIGNA systems

141

Provider Relations Coordinator Resume Examples & Samples

3 years related experience in health plan marketing to physician, physician relationship between hospital and physician
Knowledge of hospital or provider office setting required
Knowledge of managed care and integrated delivery networks
Knowledge of accountable care organizations care desired
Promotes professionalism in appearance, respect for others, positive attitude, and confidentiality
Promotes a team environment, willing to assist others, and responds timely to providers and hospital staff
Must be able to multi-task numerous initiates and work efforts
Conducts oneself professionally and courteously during interactions with others

142

Provider Relations Specialist Resume Examples & Samples

AA degree preferred or equivalent work experience
2 years sales and/or account or vendor management experience
Ability to draft clear, concise and grammatically-correct communications to providers and other constituents
Ability to clearly and efficiently communicate telephonically with providers
Willingness and ability to provide direct and constructive feedback to vendors as part of a mutually beneficial partnership
Proficient in basic Microsoft applications (Word, Excel, and Outlook) and Bright Horizons’ back-up applications (SLX, BLX, and PCA)
Motivated to meet and exceed goals as an individual as well as contribute to the success of a larger team

143

Provider Relations & Contracting Service Specialist Resume Examples & Samples

Provide pro-active and on-going communication and education to designated providers’ staff regarding HPI products, policies, procedures, and systems. This is done through regularly scheduled meetings, ad hoc meetings, phone calls, seminars, and educational in-services arranged and/or presented by the HealthPartners staff. Providers’ staff is defined as business office personnel, receptionists, training staff, referral management staff, physicians, other medical staff, clinic managers, and administrators
Review with the provider their current systems to determine if there is a need to set up new processes to effectively implement or operationalize new HPI products, policies, and procedures, taking into consideration the providers’ individual specifications, limitations, and corporate structure. Service Specialist provides suggestions to the provider on how it can design a new process/system so that compatibility exists with the operation. Service Specialist consults with both the department manager and with supervisors/managers in other internal departments to ensure a new provider groups’ operation will be compatible with HPI operations
Prepare in written form and distribute to “Provider Alert” recipients individual clinic variation information, changes, and update information to HPI staff so that internal operations reflect the most current provider status. This includes, but is not limited to, physician data, provider operations data, product participation, provider access and claims submission and processing nuances
Prepare and coordinate the creation of legal contract documents and ensure the successful implementation of contracts in accordance with the Minnesota Department of Health, government programs, accreditation, and other regulatory agency requirements
Collaborate and problem solve with internal HPI departments (Claims, Medical Services, Member Services, Membership Accounting, Accounts Payable, Clinic Operations, Support Services, Quality Utilization Management, Referral Secretaries, Government Service, Pharmacy Care Network, Other Contracting Departments and Sales and Marketing) to improve administrative efficiencies that will allow the providers to successfully deliver care to HPI members, to improve contracting opportunities for cost savings and/or to improve administrative interfaces
Serve as the department expert for his/her provider in the areas of billing, coding, market reimbursement and utilization review
Identify and implement solutions to issues and problems identified by provider groups related to HPI administration, products and programs
Participate in contract negotiation meetings, identifying administrative requirements necessary for Provider Agreements
Assist in the development of additional provider management reports identified through the participation of the Medical Group Teams, if applicable, and/or other HPI and/or provider meetings. When applicable, the Service Specialist is a member of a Medical Group Team and includes a Medical Director, Quality Assurance representative and Medical Management representatives. The Service Specialist is responsible for presenting and interpreting to key provider participants the management and financial reports developed for improving provider’s delivery of managed care services for HPI Products
Coordinate and implement new provider relationships for designated HPI products. This includes completion of a work plan, coordinate key HPI department connection with medical groups, and establish medical group team relationship
Complete special projects that are identified through provider relationships, HPI Directors or Managers. Examples of projects are designing a generic referral authorization form for provider usage, updating provider manuals, creating new product information documents, coordinating the implementation of electronic connectivity programs, creating new provider reports and streamlining internal processes that involve several internal departments
Develop and implement audit procedures to determine that contracts have been implemented correctly on the HealthPartners claims processing system
Three to five years of managed care experience in a member service, medical management, provider relations, or claims position
Excellent problem identification/solving skills
History of establishing diplomatic working relationships with providers and co-workers
Intermediate level PC skills
Strong organizational skills and ability to work independently
Current, valid, unrestricted Driver’s License (in the state of residence) free of major traffic violations or a pattern of repeated violations for the last 3 years and daily access to a reliable, insured vehicle
Four years of provider relations experience in a managed care setting (HMO, PPO)
Provider perspective as evidenced by two years’ experience in a healthcare setting

144

Provider Relations Lead, Medicaid ACO Resume Examples & Samples

Support developing strategy for provider education and support regarding implementing a Medicaid ACO program in Massachusetts, with a particular focus on payer/contracting aspects of implementation
At leadership direction, execute strategy developed (per above) to support providers transitioning into accountable care programs, including the Medicaid ACO program in Massachusetts
Develop supports for provider education and outreach related to accountable care programs across Steward's markets nationally
Serve as the primary point of resolution for Steward network providers with inquiries related to contracts, payment, claims, etc. in conjunction with the implementation of our Medicaid ACO program, as well as future programs nationally
Coordinate with enrollment team to support primary care providers' Medicaid payer transition, as applicable
Maintain project plans and action items related to scope of responsibilities
Support Regional Practice Directors as they field provider inquiries as new accountable care programs are implemented
Coordinate onboarding activities for new providers and provider groups joining Steward Health Care Network in Massachusetts and nationally in collaboration with Regional Practice Directors and Provider Enrollment
Strong relationship building and management skills
Strong organizational skills and demonstrated follow-through on commitments
Work as a team player
Communicates clearly and succinctly; strong writing and oral communication skills
Data driven with analytic approach to problem solving
Significant experience in health care settings, including providers and payers; experience with accountable care organizations preferred
Knowledge and experience with Medicaid managed care and Massachusetts health care programs
Ability to work in a fast-paced, start-up environment

145

Associate Director, Provider Relations Ltss Resume Examples & Samples

Credential, enroll and train providers
Perform prior authorization and utilization management as directed by MassHealth
Conduct analyses on utilization and quality patterns
Support providers’ claim inquiries
Strengthen program integrity
Establish leadership, structure, policies and procedures, monitoring and oversight processes to ensure overall outcomes and optimal provider experiences
Oversight of Provider Relations Representatives Specialists and Enrollment & Revalidation team members
Actively participate in client meetings to identify improvement opportunities promptly and continue to enhance operations and provider experience
Develop training materials for internal staff and the provider community
Oversee onsite LTSS Provider visits made by Enrollment & Revalidation team members
Review Provider Scorecard and develop annual Provider Quality Performance Plan
Review annual Provider and Member survey results and develop actionable improvement plan
Review and coordinate monthly quality reporting - Call Center, turnaround times, enrollment activities, credentialing/revalidation activities
Identify outlier providers who require technical assistance and use rapid cycle improvement technologies (Plan-Do-Study-Act) to improve their administrative and /or care delivery practices
Support continuous improvement of annual employee engagement scores
3 years management experience
Ability to effectively manage office based and remote staff
Strong data analytical skills with the ability to leverage best practices
Ability to build and maintain relationships
Ability to present complex data clearly and concisely to external clients
3 years’ experience in provider enrollment, credentialing and recredentialing activities
3 years’ claims servicing experience
3 years’ experience with process/quality improvement activities

146

Senior Provider Relations Manager Resume Examples & Samples

Assume role in researching provider complaints and issues, collaborating with staff from various internal operations areas to determine root causes. Remedy these problems, being on point to communicate with providers throughout the course of problem resolution
Take the front line in establishing and maintaining strong communications with providers
Develop and maintain strategic and tactical approaches to relating to high-impact providers in the network that will distinguish Magellan in the industry and result in peak provider satisfaction and network stability
Establish and maintain optimal communication channels with client provider relations and account management to foster confidence in Magellan's abilities to rapidly resolve provider issues
Identify opportunities for promoting broader use of web services and proactively communicate with providers not taking full advantage of these services to understand why. - Identify providers not availing themselves of EDI and EFT and proactively communicate with them to transition them to these platforms
Conduct telephonic, web-based and onsite training sessions (individual and group) for new network participants (rendering providers) and for ordering providers during new client implementation phases
Conduct training sessions for clients' provider relations and call center staff so as to equip them with the background knowledge of processes to assist in their ongoing training of their network providers
Routinely monitor provider performance to target and perform remedial training sessions based upon area of need (e.g., authorization processes, claims submissions, etc.)

147

Provider Relations Manager Resume Examples & Samples

Scheduling, leading and reporting on provider site visits
Works with Manager of Provider Relations to plan and present provider events, including Provider Advisory Councils and Provider Appreciation Breakfasts in all markets; Performs active outreach to ensure compliance with access and availability
Works with providers and network operations to ensure provider data submission and accuracy
Assists in provider recruitment in new networks
Reviews claim reports for denial rates and works with providers to improve claim submissions
Assists with network reporting activities
Processes and responds to providers interested in joining Beacon’s network
Participates in the coordination and processing of all Network department mailings
Travel required as necessary to satisfy job responsibilities

148

Physician / Provider Relations Administrator Resume Examples & Samples

Responsible for general oversight of provider network financials, including monthly action plans, reviews, and verification
Provides guidance on strategic plans, vision, and action plan development for the networks to include budget development, product bids, and geographic expansions
Verifies capitation checks and claims payments
Responsible for network development, including physician contracting, rate negotiations, physician network relationships, physician network communication, physician recruitment, and network partners
Participates in network and company meetings, including physician board of directors, quality management, financial/bonus, Financial Review and Complete Health Team meetings
Assists with execution of key initiatives, such as CMS STARS and coding activities
Supervises others, including but not limited to Network Operations Representatives

149

Manager of Provider Relations Resume Examples & Samples

Product, service or process decisions are most likely to impact multiple groups of employees and/or customers (internal or external)
5+ years of provider relations and / or network management experience
1+ years of management experience
Expert level of knowledge of claims / systems processes, contracting and reimbursement methodologies

150

Provider Relations Administrator Resume Examples & Samples

Provides guidance on strategic plans, vision, and action plan development for the Mobile market
Verifies and signs both capitation checks and claims payments
Responsible for execution of key initiatives, such as CMS STARS

151

Director, Provider Relations Resume Examples & Samples

Seven or more years extensive provider network management/health care management experience
Strong project management experience plus previous supervisory/management experience required
Experience in a health care management environment, including exposure to provider servicing, benefits interpretation, and internal operations of provider relations function

152

Provider Relations Services Specialist Resume Examples & Samples

Coordination of contracting and credentialing process for all Anthem products and networks
Work as a liaison with large provider organizations, IPA’s, PHO’s, hospital physician group administrators, billing companies, and internal Anthem Departments
Oversee provider updates such as demographic changes, rate changes, and provider additions and deletions
Monitor and resolve provider issues/concerns received through internal tracking tool
Research provider issues and follow up on a timely basis
Assist in auditing provider database to ensure integrity of provider data
Interact with all applicable internal departments to build positive working relationships
Work collaboratively with Network Relations Consultants
Requires H.S. diploma; college level education completed or in progress preferred but not required if candidate demonstrates strong aptitude
Advanced problem-solving skills required
Health insurance or managed care industry knowledge beneficial
Advanced written and oral communication skills required
PC skills required, including MS Office applications such as Word, Excel, PowerPoint and Outlook
Some analytical skills required
Ability to multi-task and prioritize work assignments
Ability to adapt to change; accountable in team work environment is essential

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