Provider Relations Rep Job Description
Provider relations rep
provides resources and oversees provider relations representatives and provider operations coordinators ,provider claims issues and provider service functions.
Provider Relations Rep Duties & Responsibilities
To write an effective provider relations rep job description, begin by listing detailed duties, responsibilities and expectations. We have included provider relations rep job description templates that you can modify and use.
Sample responsibilities for this position include:
Knowledge of various provider payment methodologies and strong knowledge of claims processing required
Responds to provider calls on the Provider Services Line queue emails, voicemails and faxes seeking assistance
Must maintain up to date knowledge of TRICARE and ValueOptions policies, processes, and programs
Responsible for monitoring provider and facility network adequacy, recruitment, education, respond to and document all inquiries
Ensure demographic information and facility POCs are accurate by verifying during each provider/facility contact
Provide administrative support to the PRR team
Maintain punctuality and regular attendance
Responding to provider calls on the Provider Services Line queue emails, voicemails and faxes seeking assistance
Facilitate and conduct all provider/facility education to assigned network providers according to segmentation criteria
Work within an inter-disciplinary team geared towards improving network performance
Provider Relations Rep Qualifications
Qualifications for a job description may include education, certification, and experience.
Education for Provider Relations Rep
Typically a job would require a certain level of education.
Employers hiring for the provider relations rep job most commonly would prefer for their future employee to have a relevant degree such as Bachelor's and Associate Degree in Education, Business, Health Care, Health Care Administration, Associates, Healthcare, Health, Management, Business/Administration, Healthcare Management
Skills for Provider Relations Rep
Desired skills for provider relations rep include:
Various quality programs
Community
State and federal laws and resources
Various provider payment methodologies
Experience in provider benefits administration/health care setting
HMO
PHO and Managed Care claims operations
PPO
Provider billing functions
TPA
Desired experience for provider relations rep includes:
Works with appropriate support staff to coordinate and execute POD Provider and Manager Meetings
Monitor provider and facility adequacy, recruitment, education, respond to and document all inquiries
Provide administrative support to the Provider Relations team
Maintain up to date knowledge of the contract and company policies, processes, and programs
Recruitment and Network Monitoring
Recruitment and Network Monitoring – Research and identify new providers for recruitment into the ValueOptions Federal Services inc. provider network
Provider Relations Rep Examples
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Provider Relations Rep Job Description
Job Description Example
Our growing company is searching for experienced candidates for the position of provider relations rep. We appreciate you taking the time to review the list of qualifications and to apply for the position. If you don’t fill all of the qualifications, you may still be considered depending on your level of experience.
Responsibilities for provider relations rep
- Recruitment and Network Monitoring – Research and identify new providers for recruitment into the provider network
- Assure that all provider orientations, site visits, access and availability studies are completed within designated timeframes
- Conduct Access and Availability studies as needed
- Investigate and resolve member complaints regarding providers to maintain member and provider satisfaction
- Proactively identify provider needs and advise management so that action can be taken to address the needs before they are problematic for the provider
- Stays abreast of regulatory, legal and legislative issues and requirements and communicates changes internally to appropriate providers
- Complete the Website Registration Form requests received via e-mail or fax from providers
- Process mail on a weekly basis and maintain the mail log spreadsheet
- Separate mail between letters of intent, credentialing and re-credentialing applications, waivers, appeals, contracts and change of address requests for the Supervisor and/or Director, Network Operations to review
- Follow up on missing Exhibit As - Contracted Sites and Participation Agreements for newly contracted providers
Qualifications for provider relations rep
- A minimum of 2 years’ experience working with Medicaid claims/policies and procedures knowledge required
- Extensive CMS-1500, UB-04 and ADA claim knowledge
- Required - Intermediate proficiency working in Microsoft Word, Excel and Outlook
- Bachelor's degree in Business Administration, Health Care Administration
- Follow up on missing Exhibit As – Contracted Sites for recent rate increases, changes of addresses, provider file updates
- Create and send Member letters to Members regarding notification of terminated providers in accordance with the commonwealth contract
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Provider Relations Rep Job Description
Job Description Example
Our innovative and growing company is hiring for a provider relations rep. Thank you in advance for taking a look at the list of responsibilities and qualifications. We look forward to reviewing your resume.
Responsibilities for provider relations rep
- By close of business every Friday, all received Exhibit As – Contracted Sites and Participation Agreements must be date stamped, logged into the mail log and scanned into Network Connect
- Follow up with practitioners and facilities for the return of completed credentialing and re-credentialing applications
- Email all re-credentialing/credentialing applications, tracking all applications received and give to the department supervisor for distribution
- QA re-credentialing/credentialing applications
- Update CAS after Local Credentialing Committee (LCC) meetings
- Reviews the provider credentialing listing and non-compliant provider reports generated from the Credentialing Department to ensure that provider information is prepared and ready to present to the IPA Board of Directors binders
- Works well with coworkers and is a good team player
- Quality Performance and Improvement– Collect and interpret provider performance data and review with the provider during face to face meetings on a regularly scheduled basis as part of a continuous quality improvement process
- Provider Data Entry, Maintenance, Verification/Provider Recruitment
- Develop and maintain strong relationships with assigned network physicians/providers through routine visits, in-services, teleconferences and correspondence
Qualifications for provider relations rep
- Should reside in or near Onondaga County
- Experience in behavioral health or managed care environment preferred
- Collaboration and team oriented philosophy
- Ability tot apply common sense understanding to carry out instructions furnished in written, oral, or diagram form
- Experience in Medicaid
- Insurance or Healthcare experience
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Provider Relations Rep Job Description
Job Description Example
Our growing company is looking for a provider relations rep. We appreciate you taking the time to review the list of qualifications and to apply for the position. If you don’t fill all of the qualifications, you may still be considered depending on your level of experience.
Responsibilities for provider relations rep
- Provide initial orientations to new providers/physicians and their staff in order to ensure compliance with Plan's rules and regulations
- Continually assess the needs of additional and/or ongoing education of current providers/physicians
- Determine trends within claims issues and appeals and works with appropriate staff to correct ongoing issues whether internally (i.e., system issues, processing errors, ) or as part of ongoing education with providers
- Educate providers through provider profiling and analysis on HEDIS or other measures
- Educate providers on compliance expectations with applicable federal and state rules and regulations, and plan policies and procedures
- Assist in the development of the department through the development/enhancement and implementation of new departmental process, policies and/or procedures
- Attend meetings for Plan as necessary
- Act as a resource for providers about Beacon, its contracts, policies and procedures
- Answer general provider questions about Beacon, its contracts, policies and procedures
- Perform research and problem resolution on issues related to provider complaints, claims reported to have been processed incorrectly, coordinating credentialing paperwork, provider communications, or verification of information as requested
Qualifications for provider relations rep
- Customer service - Medical billing/1-3 Years
- Communications/Provider communications/1-3 Years
- Administration / Operations/Travel/1-3 Years
- Should reside in or near Orange or Putnam County
- Bachelor s Degree in Health Care Administration or related field, preferred
- Minimum three years of experience in provider relations, provider contracting or health plan operations
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Provider Relations Rep Job Description
Job Description Example
Our growing company is searching for experienced candidates for the position of provider relations rep. To join our growing team, please review the list of responsibilities and qualifications.
Responsibilities for provider relations rep
- Provide assistance in compilation and mailing of provider recruitment mailings, general information, and educational materials to network practitioners as required
- Conduct outreach to providers for information, research or compliance with Beacon policies or programs including access and availability standards
- Provide follow up with key practitioners and facilities for the return of completed credentialing and re-credentialing applications
- Respond to provider calls transferred by the Provider Services Line emails, voicemails and faxes
- Actively outreach and train providers to increase the rate of electronic transactions
- Perform active outreach to ensure compliance with access and availability
- Work with providers and network operations to ensure provider data submission and accuracy
- Participate in the coordination and processing of all Network department mailings
- Review claim reports for denial rates and work with providers to improve claim submissions
- Build collaborative relationships with client health plan counterparts to ensure seamless customer service
Qualifications for provider relations rep
- Ability to present to ACO and physician practice leadership
- Accountable Care, Population Health and/or Medical Staff knowledge preferred
- Health Plan network adequacy and credentialing process will be recognized
- BA/BS - Bachelors Degree or equivalent preferred or Equivalent Experience
- Should reside in or near Nassau County
- Minimum 2 years’ experience in health care field
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Provider Relations Rep Job Description
Job Description Example
Our company is searching for experienced candidates for the position of provider relations rep. To join our growing team, please review the list of responsibilities and qualifications.
Responsibilities for provider relations rep
- Be available during working hours to coworkers and others for questions
- Locate and negotiate rates with non-par providers for member placements
- Serve as a direct contact for member placement issues from the health plan
- Assist with administrative duties, provider surveys and departmental projects as assigned
- Complete required documents for member placements
- Understand the language within Provider Agreements and Letters of Intent
- Process Specialty Referral requests in accordance with market placement guidelines
- Maintain data on providers to ensure use of most efficient providers
- Position will be temporary work from home until further notice
- Develops revenue cycle educational programs/written materials for assigned internal and external customers
Qualifications for provider relations rep
- Flexcare
- Should reside in or near Genesee, Livingston or Monroe Counties
- One or two years experience in a medical environment dealing with managed care or insurance issues
- Should reside in or near Orange County
- Must have claims processing knowledge and experience
- Should reside in or near Bronx County