Provider Relations Resume Samples
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Provider Relations Resume Samples
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LF
L Feeney
Lindsey
Feeney
12412 Maryse Springs
Houston
TX
+1 (555) 466 3889
12412 Maryse Springs
Houston
TX
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
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
15 Provider Relations resume templates
Read our complete resume writing guides
1
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
2
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
3
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
4
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
5
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
6
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
7
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
8
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
9
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
10
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
11
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
12
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)
13
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
14
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
15
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
16
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
17
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
18
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
19
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
20
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
21
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
22
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
23
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
24
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
25
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%)
26
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
27
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
28
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
29
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
30
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
31
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
32
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
33
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
34
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
35
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
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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
37
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
38
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
39
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
40
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
41
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
42
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
43
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
44
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
45
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
46
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
47
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
48
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
49
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
50
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
51
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
52
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
53
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
54
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
55
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
56
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
57
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
58
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
59
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)
60
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
61
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
62
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)
63
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
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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
65
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
66
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
67
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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
