Provider Relations Representative Resume Samples - Page 3

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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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21

Provider Relations Representative

  • Provide excellent provider in-servicing and ensure physicians have access to key resources and information regarding the organization's structure and strategy
  • Interface with providers and provider office staff to research and gather information to resolve claim, clinical and administrative issues for the provider
  • Train network providers and provider office staff on various tools to assist them in reviewing and understanding financial, capitation and contractual terms
  • Oversee provider training and quarterly staff education and office manager meetings
  • Maintain regular monthly contact with key providers, provider groups, provider organizations and their respective office staff and build strong and trusted working relationships
  • Develop and facilitate effective provider communications and distribute to provider network
  • Schedule, perform and document credentialing site visits and follow-up site visits
  • Respond to all provider calls and emails within 24 hours
Candidate Info
26
years in
workforce
6
months
at this job
22

Provider Relations Representative

  • Managing Fulton County network by developing and maintaining strong business relationships.
  • Educating and training office staff, providers, and large IPAs on HEDIS data, claims and billing inquiries, provider contracts, and credentialing information.
  • Increasing provider satisfaction scores by collecting credentialing and demographic updates, overseeing network integrity, and investigating claims and billing inquiries.
  • Attending provider conferences and seminars to setup and present materials, answer inquiries, and market the Plan.
  • Resolving member and provider grievances and ensuring appropriate follow-up with internal and external departments.
  • Preparing and distributing network analytics and provider forms, including pharmacy profiles, ER contingencies, Frequent Flier reports, and Quick Reference Guides (QRGs).
  • Managing various provider relations MEI projects and providing updates in tracking databases for reporting to senior management.
Candidate Info
15
years in
workforce
2
years
at this job
BS
Health Care Management
23

Provider Relations Representative III

  • Maintain network participation by providing support to dentists and dental office managers to improve their understanding of all available benefit programs.
  • Educate providers by instructing and advising of the comprehensive policies and procedures involving all phases of the corporation’s benefits and contracts through office visits and communication over the phone and email.
  • Recruit non-participating providers to join our networks.
  • Negotiate special deals to maintain compliance and increase access in weak networks.
  • Facilitate Oral Health presentations to various educational institutions and organizations.
  • Serve as a liaison with dental offices by answering remittance, payment, benefit, claims, and eligibility questions when necessary.
Candidate Info
13
years in
workforce
2
years
at this job
HS
High School Diploma
BS
Healthcare Management
24

Provider Relations Representative

  • Maintains regular contact with key provider organizations and serves as a liaison to internally resolve complex issues; develops strong interpersonal relationships with assigned providers
  • Researches and resolves incoming escalated provider inquiries within contract guidelines; educates providers on new protocols, policies, and procedures
  • Assists with physician recruitment as necessary by identifying specific providers within a designated territory, facilitating the distribution of provider agreements, negotiating rates for new physicians, and renegotiating contracts for existing physicians within established limits
Candidate Info
9
years in
workforce
5
months
at this job
C
Certificate
BA
Business Administration
MA
Business Administration
25

Provider Relations Representative

  • Analysis of financial documents to determine if financial assistance was needed for patients.
  • Enter new account referrals.
  • Enrolled members into Medicaid/Medicare programs
  • Communicated information between providers and members
  • Providing information to providers pertaining to member eligibility, appeals, claims, cpt codes, and authorizations
Candidate Info
11
years in
workforce
26

Provider Relations Representative

  • Serve as primary contact for Medicaid & Medicare providers (hospitals/health systems, physician groups, practitioners, skilled nursing facilities, home based community services, FQHC) functioning as a liaison between the provider and the health plan based on assigned regional territories
  • Educate and train providers regarding health plan policies and procedures related to authorizations and claims submission, web site education, PHI Web Portal, HEDIS measures, EDI solicitation and problem solving
  • Provide medical billers with basic understanding of billing ICD 9 & ICD 10 codes for claim submission
  • Conduct bi-weekly face to face meetings and presentations with providers documenting discussions, issues, attendees, and action items researching claims issues onsite and routing to the appropriate party for resolution
  • Advise provider on health plan and Federal/State related healthcare law changes and updates
  • Assist with Provider contractual policies and procedure interpretation by researching, analyzing and resolving complex problems relating to claims, appeals, grievances and eligibility
  • Update provider orientation and training materials based on Federal, State, and/or Health Plan health program changes
  • Prepare, distribute, and analyze State required Provider Network Adequacy report(s) to management team and healthcare quality auditor improvement vendor company
  • Create and develop management level reports and dashboards on daily department operations
Candidate Info
11
years in
workforce
2
years
at this job
BA
Marketing Communications
MA
Health Administration
27

Senior Provider Relations Representative

  • Provide accurate and timely customer service to our through routine telephone inquiries and written correspondence both simple and complex
  • Review and resolve simple and complex provider issues, claims questions, provider contract issues, and patient inquires which directly impacted our provider's daily business practices.
  • Communicate claim status, enrollment/membership and benefit policy and procedures to providers
  • Maintain excellent quality since hired
  • Participate with Showing /Buddy sessions with new hires and seasoned reps that had refresher training. Demonstrated ways to navigate and see how all applications work.
  • I have been crossed training in several lines of business such as IPP, ASO, State PPO and Commercial.
  • Participated in the process of hiring new service representatives
Candidate Info
13
years in
workforce
2
years
at this job
GED
GED
28

Provider Relations Representative

  • Loaded providers by NPI number to the correct Tax Id Number in system
  • Verified information of providers to ensure payment was mailed to correct address
  • Customer Service
  • Assist members in locating providers for specific needs or in certain areas
  • Customer service
  • Other duties as assigned
Candidate Info
12
years in
workforce
3
months
at this job
HS
High School Diploma
AS
Paralegal
29

Provider Relations Representative

  • Calling providers who have inquired about joining the network
  • Fielding provider contract and claims issues
  • Work in conjunction with Network Account Managers in regards to physician groups
  • Answer provider inquiries via email, telephone, and written correspondence
  • Contract new providers to an existing provider group
  • Research and assists in the resolution of regulatory inquiries and/or DOI complaints
  • Facilitate the resolution of credentialing issues and coordinates, and complete external and internal termination notification requirements
Candidate Info
7
years in
workforce
3
years
at this job
Business Marketing
30

Senior Provider Relations Representative

  • Serves as liaison between [company name] and provider community in multiple counties.
  • Responsible for physician recruitment and contracting, database management and Access and Availability audits.
  • Investigate and respond to inquiries from Grievance and Appeals, Customer Service, Credentialing, Claims and other departments.
  • Completes needed record retrieval for state and government audits.
  • Identify network gaps and work with Network Development team to fill deficiencies.
Candidate Info
13
years in
workforce
5
years
at this job
BA
Community & Human Services

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