Provider Relations Representative Resume Samples - Page 4

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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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31

Provider Relations Representative

  • Recruit and contract physicians to participate with ACO, CI risk and non-risk contracts.
  • Maintain strong relationships with 500+ assigned providers.
  • Provide provider orientation and education on contracts policies and procedures.
  • Research and resolve all provider claim, referral, credentialing, and contracting issues
  • Negotiate rates and contracts with out-of-network providers as needed.
  • Collect provider credentialing information and insure CAQH is current.
  • Visit bi-annually the top 50 primary care and specialist physicians.
  • Provide training and guidance to new Provider Relations Representatives.
  • Attend and participate in Local Leadership Council (LLC) meetings and serves as a liaisons between PHP leadership, Physicians, and LLC members.
Candidate Info
19
years in
workforce
9
months
at this job
BA
Psychology
32

Inside Provider Relations Representative

  • Maintained relations with providers to ensure the partnership with the health plan was successful.
  • Processed provider credentialing applications in accordance with accreditation standards, regulatory requirements and policies and procedures.
  • Accountable, on a monthly basis, to confirm each provider that was due for recredentialing had the proper licenses, insurance, work history, etc. in order to maintain the relationship with the provider and the health plan.
Candidate Info
9
years in
workforce
8
months
at this job
33

Provider Relations Representative

  • Assist in building and nurturing positive relationships between the health plan, providers and practice managers.
  • Identify HEDIS care opportunities and provider services to prioritize member needs in seven counties in the NJ Market.
  • Familiar with UnitedHealthcare, Oxford, Medicare and Medicaid lines of business, policies and procedures.
  • Analyze and optimize healthcare according to Medicare STARS program and National HEDIS Regulations.
  • Investigate both routine and non-standard provider related problems and issue resolution, demographic, clinical and market incentive
  • Independently prioritize and organize own work to meet departmental and organizational deadlines.
  • Communicate effectively with physicians and their office staff as well as with both the Provider Advocate and ACO Teams.
  • Provide support to ensure complete contract compliance. Understands and works in accordance with HIPAA guidelines and rules.
  • Knowledge of CMS reimbursement methodologies in terms of The Resource-Based Relative Value Scale (RBRVS).
Candidate Info
5
years in
workforce
11
months
at this job
Marketing Management
34

Provider Relations Representative

  • Provide professional and responsive customer service to dental providers
  • Answer all provider inquiries regarding claims and system errors
  • Create and update provider records in FACETS and Salesforce systems
  • Verify and update provider demographic information
  • Work Outbound call projects and Provider Directory Audit projects
  • Train team members and new hires on current processes
  • Create Policies and Procedures as needed
  • Utilize necessary resources and navigate systems efficiently to accurately verify information for providers
Candidate Info
17
years in
workforce
7
years
at this job
35

Provider Relations Representative

Provider Relation

  • Assists in the maintenance of provider manual.
  • Maintains records in accordance with corporate policy and/or regulatory requirements.
  • Assists in annual provider network availability and accessibility standards and provider satisfactions surveys.
  • Participate in education programs for providers and their staffs regarding new provider systems.
  • Provides face-to-face meeting with providers to address communication issues and concerns.
  • Manages electronic claims submissions and reception checks from CMS and other issuance agencies.
  • Assists project development.
  • Assists providers to address meaningful use concern and PQRS reporting.
  • Sales EMR services.
  • Responses and resolves customer services inquiries and issues regarding EMR systems.
Candidate Info
2
years in
workforce
2
years
at this job
BS
Business Administration
36

Provider Relations Representative

  • Acts as the primary contact for assigned groups, Health Centers and Individual providers.
  • Meet with community based physicians and physician groups on a regular basis to identify problems and/or concerns; maintain relationships with key contacts to ensure and support mutually beneficial relationships and ongoing collaboration. Giving presentations to new and existing providers and provider groups.
  • Work with internal staff to resolve provider issues with regards to billing, payments, denials, authorizations and other interactions.
  • Manage the provider relations mailbox; triage inquiries, facilitate resolution of incoming requests and/ or forward such requests as appropriate.
  • Follow up with providers regarding confirmation of changes, and maintaining appropriate documentation.
  • Assist Network Development in ongoing identification of providers need for network completion or expansion (physicians, ancillary providers, community agencies, advocacy groups, etc.) And assist Network Development in recruitment of providers.
  • Distribution and collection of provider contracts, preparation of complete contracts/application packets for credentialing process and maintain ongoing practioner credentialing efforts for large providers.
  • Function as a designated responder for provider relations call line- respond to calls on eligibility, authorization and benefit questions.
Candidate Info
11
years in
workforce
3
years
at this job
37

Provider Relations Representative

  • Coordinating completion of credentialing
  • NPI applications
  • Draft letters of interest to Health Plans
  • Maintain rosters for national contracts
  • Responsible for database accuracy
  • Issue resolution with the health plan
  • Claims resolution
  • Department of Labor enrollment
  • Tricare enrollment
Candidate Info
9
years in
workforce
1
year
at this job

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