Provider Relations Representative Resume Samples - Page 2

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Provider Relations Representatives build and cultivate relationships with users and ensure a high level of customer service. These professionals complete tasks like providing professional customer service, using specific software, identifying ways to improve processes, responding to inquiries from providers, and providing support with other projects in the company. Based on our selection of resume samples in the field, the most sought-after assets are technical skills, customer service orientation, conflict resolution, relationship management, and strong communication and interpersonal abilities. The ideal candidate should be able to showcase in his or her resume a Bachelor’s Degree in business or another relevant field.

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11

Provider Relations Representative

  • Provide education to Medicare Durable Medical Equipment (DME) suppliers on policies and regulations related to claims processing
  • Utilize teleconference, webinar, online video and face-to-face delivery methods
  • Develop and write specific supplier education that focuses on reducing claims error rates
  • Identify suppliers through data analysis that would benefit from education
  • Perform ongoing quarterly analysis of claims data for identified suppliers that focuses on addressing additional education gaps
  • Contribute to planning and development of webinars, workshops and tradeshows
Candidate Info
12
years in
workforce
2
years
at this job
BA
Management And Human Relations
MS
Management
12

Provider Relations Representative

Serving as liaison between civilian providers and the Military Treatment Facilities providing education and training for network providers/staff/suppliers/physicians/beneficiaries/referral agents as necessary

  • Develop/prepare/review/update provider education material including web-based and computer training.
  • Develop relationship with providers, staff, referral agents, state/local medical professional associations.
  • Responds to and resolves issues identified through meetings, workshops, correspondence, etc.
  • Produces and generates various reports on network enrollment and status
  • Completes special projects as directed.
Candidate Info
13
years in
workforce
2
years
at this job
BS
Psychology / Criminology
MA
Master of Arts
Medical Assistance/phlebotomy
13

Provider Relations Representative

Performed audit on provider directory

  • Made outbound calls to providers to verify and confirm accuracy of information on directory
  • Prepared corresponding reports and recommendations daily
  • Strictly observed confidentiality of information
Candidate Info
46
years in
workforce
2
months
at this job
C
Human Resources Management
BA
Commerce
14

Provider Relations Representative

Provided administrative support and performs other duties as assigned.

  • Answered telephone inquiries according to established grade of service standards.
  • Collected and verified information concerning eligibility, provider status, benefit coverage, coordination of benefits and subrogation.
  • Complied with organizational policies and procedures, regulatory requirements and other established criteria and guidelines.
  • Assisted in preparing and submitting reports or assignments as needed to meet organizational initiatives and/or objectives.
  • Maintained confidentiality of company and protected health information.
  • Provided behavioral health customer service functions and coordinates member needs with appropriate level of care.
  • Referred members to network behavioral health providers for outpatient evaluation and treatment.
  • Performed data entry of authorizations and customer contacts in the Diamond and Prism systems.
  • Basic research and resolution of claims issues
Candidate Info
15
years in
workforce
8
years
at this job
AS
Computer Science
BA
Social Work
15

Provider Relations Representative

  • Examines Medicaid claims and reports to ensure proper recoding of transactions and compliance with client company policy and/or state and federal regulations
  • Applies knowledge of established procedures to research and resolve escalated customer questions or management requests
  • Conducts visits to Arkansas Medicaid provider locations for education and training in the billing process
  • Presents at provider workshops and is involved in other provider-related outreach, as needed
  • Researches and analyzes claim processing outcomes, identifies issues and reports as necessary, and proactively outreaches to peers, Supervisor, and/or providers upon findings
Candidate Info
9
years in
workforce
9
months
at this job
BBA
Healthcare Management
MA
Business Administration
16

Provider Relations Representative

  • Preform site reviews to service providers, help with issues, educate the staff and/or providers on policies, assist with credentialing process and review HEDIS information with the providers.
  • Make provider calls and visits within the frequency goals established to have and maintain a strong relationship with providers.
  • Complete new provider orientation for all applicable Wellcare product lines.
  • Assist Network Development in identifying network gaps.
  • Provide oversight on claims issues and inquiries. Have follow up with the providers to ensure resolution has been
Candidate Info
29
years in
workforce
2
years
at this job
HS
High School Diploma
17

Provider Relations Representative

Child Care Provider

  • Took children to and from school
  • Assisted and supervised children in homework completion
  • Coordinated and played educational games with children
  • Registered new incoming children
  • Handled children's primary needs
Candidate Info
17
years in
workforce
8
years
at this job
HS
High School Diploma
AS
Associate of Science
BS
Business Administration
18

Provider Relations Representative

  • Won 5 - 6 "Above the Line" awards per year for superior customer service based on provider recognition
  • Deliver exceptional customer service for 20-35 healthcare providers per day by receiving, reviewing and analyzing medical documents for claim payment determination. Answering questions related to claims as well as provider enrollment status, credentials and limitations
  • Process 30 - 40 inquiries per day to follow up on open claims for providers by verifying information in files such as HIPAA forms and claim forms necessary for reimbursements while ensuring diagnoses match billing codes
  • Collaborate with team of 12 representatives to stay abreast of HIPAA regulations and the healthcare marketplace, policy changes, best practices, and to manage files in their absence while working with providers such as physicians, physician assistants, nurses, and psychologists regarding health care products including PPO, EPO, traditional coverage, national health reform and market-place policies
  • Respond to inquiries regarding plan policies, procedures, membership eligibility, benefits and claims ensuring highest level of client service in support of unit goals and objectives
  • Develop strong working relationships with network providers to facilitate resolution to issues while promoting BCBSM initiatives promoting wellness programs for members
Candidate Info
14
years in
workforce
7
years
at this job
AA
Associate of Arts
19

Provider Relations Representative

  • Responsible for education to all contracted specialists and ancillary providers in the San Antonio market
  • Provide scheduled in-services for all new contracted providers with presentation material an overview of protocols and processes for Medicare Advantage population.
  • Maintain and update all demographic changes, new provider on-boarding and education on payor relationships.
  • Seek to provide root cause analysis on claims discrepancies; grievances and provider concerns.
  • Seek to reduce final risk by utilizing data in the development and implementation of managed care and reimbursement by educating providers on the network contracted providers
  • Evaluates proposals for specialists, sub-capitated providers and some ancillary providers, recommends options based on costs, changes, services and needs of members to determine network adequacy.
  • Communicates the results of data analysis and strategic planning to various audiences.
  • Resolve complex, difficult and /or routine provider inquires and/or problems and facilitates resolution of provider issues, striving to ensure that favourable relationships are maintained.
Candidate Info
34
years in
workforce
12
years
at this job
20

Provider Relations Representative

  • Provide physician and practices with overview of Medicaid/Medicare product line and educate them on any changes, how to do referrals and use of the internet tools
  • Review incentive opportunities with practices to enable them to gain bonus/incentive monies through patient care
  • Review claims issues, denials and any potential trending on coding that may have affected claim
  • Worked with physician practices for credentialing of physicians and set up internally
  • Managed physician set up and departure processing
  • Responsible for all practices in York and Adams counties and traveled to meet with physician practices as needed
Candidate Info
21
years in
workforce
2
years
at this job
HS
Medical Assistant

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