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Provider Relations Representative Resume Samples
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0-5 years of experience
Responsible for daily interaction with providers and staff to ensure provider satisfaction and to achieve targeted goals for Bergen, Passaic, Hudson, Essex, Union, Warren, Sussex and Morris counties, in addition to 4 counties in Pennsylvania.
- Planned, organized and conducted orientations and site visits
- Recruited physicians in accordance to network requirement goals
- Negotiated and renegotiated contracted with physicians/physicians group
- Assisted in credentialing and re-credentialing process to ensure provider’s applications are correct and expedited. Claim resolution.
- Built and maintained professional relationships with the providers to ensure provider satisfaction
0-5 years of experience
- Researched and resolved disputes, billing discrepancies and claims immediately with regard to customer satisfaction
- Established and fostered strong, positive relationships with key providers by coordinating, facilitating and leading partnership meetings and identifying on site enrollment opportunities for marketing
- Prepared and reviewed claims and ensured that claims were executed and paid in a timely manner
- Investigated and resolved member complaints regarding providers to maintain member and provider satisfaction
0-5 years of experience
Acted as a liaison between Providers and the company regarding contract and data compliance. Held meetings with providers to review new policies, products and issue resolution.
- Secured and serviced contracts with large health care systems, clinics and individual provider offices for network expansion.
- Proofed, updated and distributed provider directories for Southeastern and South Central Wisconsin provider networks.
- Co-chaired HealthPlan Credentialing Committee.
- Performed NCQA compliant site audits of Primary Care Providers.
0-5 years of experience
- Addressed and resolved provider issues regarding reimbursement, proper utilization of policies and procedures, and coordination of resolution through provider education.
- Maintained technical knowledge regarding Independent Health’s contracts and benefits and working knowledge of policies and procedures.
- Utilized Power MHS and Core Plus systems for obtaining benefit and claims information. Documented correspondence using the IMAX system.
6-10 years of experience
Provide servicing and support to the provider network in Central PA including 100 PCP offices, 130 specialty groups, Holy Spirit Hospital, Pinnacle Physician Network and Hershey Physician Network.
- Respond to provider/hospital inquiries concerning contract and claims issues.
- Provide physician/hospital orientations to support ongoing education of health care provider community.
- Develop and deliver presentations on various Gateway topics to the provider community.
- Awarded “Recognition of Excellent Customer Service” in 2008 and 2009.
0-5 years of experience
- Verified provider applications for completeness, initiated the credentialing/re-credentialing process including Site Survey visits
- Conduct new provider orientation for primary care and specialty physicians
- Identified potential claims trends and follow-up with provider and internal departments to ensure resolution of problems
- Conducted on going trainings to provider regarding any upcoming changes, Educate provider properly on the MLR. Provide continuous face-to-face service/educational meetings ensuring provider and staff understand company policies and procedures
0-5 years of experience
- Handle inquiries from physicians, which are received by phone or email which can included billing, network status or provider issues.
- Interact with providers and hospital staff to resolve claim and benefit related issues by creating a SP ticket, in which our third party administrator will open and reprocess claims based on direction provided.
- Record and log all pertinent communication including inquiries and concerns.
- Build and maintained strong professional relationships with medical units and member service departments.
- Efficiently and accurately managed provider requests for demographic information such as tax identification numbers and new addresses.
- Responsible for LLHPHYSICIAN email box and LLH Provider Relations voicemails: intake, respond and completed all requests.
- Investigate and resolve member complaints regarding providers to ensure satisfaction at both levels
0-5 years of experience
- Responsible for proactive support of plan providers and staff including orientation, education, and the scheduling of on – site visits as well as incorporating plan’s policies and procedures and for fostering a positive perception of the plan among providers.
- Communicated provider issues to Health Net Claims Department for timely resolution.
- Facilitated smooth work flow between Network Management and various departments within Health Net on a daily basis
- Liaison between physician community and Health Net’s Medical Management Team
- Developed working relationships with upper management of hospital based faculty practices and large multi physician specialty groups
- Facilitated projects in a timely manner and prioritize according to provider needs
0-5 years of experience
Maintain regular contact with providers and act as a liaison to resolve claims and complex issues.
- Responsible for completing the annual Provider Incentive Payment (PIP) Report.
- Recruit providers for Medicare duals product.
- Responsible for uploading and verifying information for the monthly and annual provider directory.
- Responsible for ensuring that the 4275 weekly report (Provider Report for the State) is free of errors.
- Educate providers on new procedures, HEDIS reports, Healthy Michigan Plan and any new Plan initiatives.
- Collaborate with the outreach department in community events.
0-5 years of experience
- Build and maintain relationships with physicians, office staff and collaborate closely with Sales Representatives to provide a high level of customer experience.
- Review fund allocations and expenses for accounts at daily, weekly and monthly intervals to ensure surplus and deficits are credited appropriately based on payment schedules and claim submission.
- Reduce delinquency and retain customers by utilizing experience, judgement, and resources to plan and accomplish department goals.
- Responsible for cost containment efforts resulting in over 5.8 million dollars. Responsible for cost containment efforts resulting in over 5.8 million dollars.
- Serve liaison for multiple lines of business including but not limited Medicare HMO, Commercial, PPO, and Medicare Supplement.
- Serve as single-point of contact for specialist, primary care physician, multi-specialty groups and hospital systems in the Southeastern region.
0-5 years of experience
- Provide education to Medicare Durable Medical Equipment (DME) suppliers on policies and regulations related to claims processing
- Utilize teleconference, webinar, online video and face-to-face delivery methods
- Develop and write specific supplier education that focuses on reducing claims error rates
- Identify suppliers through data analysis that would benefit from education
- Perform ongoing quarterly analysis of claims data for identified suppliers that focuses on addressing additional education gaps
- Contribute to planning and development of webinars, workshops and tradeshows
0-5 years of experience
Serving as liaison between civilian providers and the Military Treatment Facilities providing education and training for network providers/staff/suppliers/physicians/beneficiaries/referral agents as necessary
- Develop/prepare/review/update provider education material including web-based and computer training.
- Develop relationship with providers, staff, referral agents, state/local medical professional associations.
- Responds to and resolves issues identified through meetings, workshops, correspondence, etc.
- Produces and generates various reports on network enrollment and status
- Completes special projects as directed.
0-5 years of experience
Performed audit on provider directory
- Made outbound calls to providers to verify and confirm accuracy of information on directory
- Prepared corresponding reports and recommendations daily
- Strictly observed confidentiality of information
6-10 years of experience
Provided administrative support and performs other duties as assigned.
- Answered telephone inquiries according to established grade of service standards.
- Collected and verified information concerning eligibility, provider status, benefit coverage, coordination of benefits and subrogation.
- Complied with organizational policies and procedures, regulatory requirements and other established criteria and guidelines.
- Assisted in preparing and submitting reports or assignments as needed to meet organizational initiatives and/or objectives.
- Maintained confidentiality of company and protected health information.
- Provided behavioral health customer service functions and coordinates member needs with appropriate level of care.
- Referred members to network behavioral health providers for outpatient evaluation and treatment.
- Performed data entry of authorizations and customer contacts in the Diamond and Prism systems.
- Basic research and resolution of claims issues
0-5 years of experience
- Examines Medicaid claims and reports to ensure proper recoding of transactions and compliance with client company policy and/or state and federal regulations
- Applies knowledge of established procedures to research and resolve escalated customer questions or management requests
- Conducts visits to Arkansas Medicaid provider locations for education and training in the billing process
- Presents at provider workshops and is involved in other provider-related outreach, as needed
- Researches and analyzes claim processing outcomes, identifies issues and reports as necessary, and proactively outreaches to peers, Supervisor, and/or providers upon findings
0-5 years of experience
- Preform site reviews to service providers, help with issues, educate the staff and/or providers on policies, assist with credentialing process and review HEDIS information with the providers.
- Make provider calls and visits within the frequency goals established to have and maintain a strong relationship with providers.
- Complete new provider orientation for all applicable Wellcare product lines.
- Assist Network Development in identifying network gaps.
- Provide oversight on claims issues and inquiries. Have follow up with the providers to ensure resolution has been
6-10 years of experience
Child Care Provider
- Took children to and from school
- Assisted and supervised children in homework completion
- Coordinated and played educational games with children
- Registered new incoming children
- Handled children’s primary needs
6-10 years of experience
- Won 5 – 6 “Above the Line” awards per year for superior customer service based on provider recognition
- Deliver exceptional customer service for 20-35 healthcare providers per day by receiving, reviewing and analyzing medical documents for claim payment determination. Answering questions related to claims as well as provider enrollment status, credentials and limitations
- Process 30 – 40 inquiries per day to follow up on open claims for providers by verifying information in files such as HIPAA forms and claim forms necessary for reimbursements while ensuring diagnoses match billing codes
- Collaborate with team of 12 representatives to stay abreast of HIPAA regulations and the healthcare marketplace, policy changes, best practices, and to manage files in their absence while working with providers such as physicians, physician assistants, nurses, and psychologists regarding health care products including PPO, EPO, traditional coverage, national health reform and market-place policies
- Respond to inquiries regarding plan policies, procedures, membership eligibility, benefits and claims ensuring highest level of client service in support of unit goals and objectives
- Develop strong working relationships with network providers to facilitate resolution to issues while promoting BCBSM initiatives promoting wellness programs for members
10+ years of experience
- Responsible for education to all contracted specialists and ancillary providers in the San Antonio market
- Provide scheduled in-services for all new contracted providers with presentation material an overview of protocols and processes for Medicare Advantage population.
- Maintain and update all demographic changes, new provider on-boarding and education on payor relationships.
- Seek to provide root cause analysis on claims discrepancies; grievances and provider concerns.
- Seek to reduce final risk by utilizing data in the development and implementation of managed care and reimbursement by educating providers on the network contracted providers
- Evaluates proposals for specialists, sub-capitated providers and some ancillary providers, recommends options based on costs, changes, services and needs of members to determine network adequacy.
- Communicates the results of data analysis and strategic planning to various audiences.
- Resolve complex, difficult and /or routine provider inquires and/or problems and facilitates resolution of provider issues, striving to ensure that favourable relationships are maintained.
0-5 years of experience
- Provide physician and practices with overview of Medicaid/Medicare product line and educate them on any changes, how to do referrals and use of the internet tools
- Review incentive opportunities with practices to enable them to gain bonus/incentive monies through patient care
- Review claims issues, denials and any potential trending on coding that may have affected claim
- Worked with physician practices for credentialing of physicians and set up internally
- Managed physician set up and departure processing
- Responsible for all practices in York and Adams counties and traveled to meet with physician practices as needed
0-5 years of experience
- Provide excellent provider in-servicing and ensure physicians have access to key resources and information regarding the organization’s structure and strategy
- Interface with providers and provider office staff to research and gather information to resolve claim, clinical and administrative issues for the provider
- Train network providers and provider office staff on various tools to assist them in reviewing and understanding financial, capitation and contractual terms
- Oversee provider training and quarterly staff education and office manager meetings
- Maintain regular monthly contact with key providers, provider groups, provider organizations and their respective office staff and build strong and trusted working relationships
- Develop and facilitate effective provider communications and distribute to provider network
- Schedule, perform and document credentialing site visits and follow-up site visits
- Respond to all provider calls and emails within 24 hours
0-5 years of experience
- Managing Fulton County network by developing and maintaining strong business relationships.
- Educating and training office staff, providers, and large IPAs on HEDIS data, claims and billing inquiries, provider contracts, and credentialing information.
- Increasing provider satisfaction scores by collecting credentialing and demographic updates, overseeing network integrity, and investigating claims and billing inquiries.
- Attending provider conferences and seminars to setup and present materials, answer inquiries, and market the Plan.
- Resolving member and provider grievances and ensuring appropriate follow-up with internal and external departments.
- Preparing and distributing network analytics and provider forms, including pharmacy profiles, ER contingencies, Frequent Flier reports, and Quick Reference Guides (QRGs).
- Managing various provider relations MEI projects and providing updates in tracking databases for reporting to senior management.
0-5 years of experience
- Maintain network participation by providing support to dentists and dental office managers to improve their understanding of all available benefit programs.
- Educate providers by instructing and advising of the comprehensive policies and procedures involving all phases of the corporation’s benefits and contracts through office visits and communication over the phone and email.
- Recruit non-participating providers to join our networks.
- Negotiate special deals to maintain compliance and increase access in weak networks.
- Facilitate Oral Health presentations to various educational institutions and organizations.
- Serve as a liaison with dental offices by answering remittance, payment, benefit, claims, and eligibility questions when necessary.
0-5 years of experience
- Maintains regular contact with key provider organizations and serves as a liaison to internally resolve complex issues; develops strong interpersonal relationships with assigned providers
- Researches and resolves incoming escalated provider inquiries within contract guidelines; educates providers on new protocols, policies, and procedures
- Assists with physician recruitment as necessary by identifying specific providers within a designated territory, facilitating the distribution of provider agreements, negotiating rates for new physicians, and renegotiating contracts for existing physicians within established limits
0-5 years of experience
- Analysis of financial documents to determine if financial assistance was needed for patients.
- Enter new account referrals.
- Enrolled members into Medicaid/Medicare programs
- Communicated information between providers and members
- Providing information to providers pertaining to member eligibility, appeals, claims, cpt codes, and authorizations
0-5 years of experience
- Serve as primary contact for Medicaid & Medicare providers (hospitals/health systems, physician groups, practitioners, skilled nursing facilities, home based community services, FQHC) functioning as a liaison between the provider and the health plan based on assigned regional territories
- Educate and train providers regarding health plan policies and procedures related to authorizations and claims submission, web site education, PHI Web Portal, HEDIS measures, EDI solicitation and problem solving
- Provide medical billers with basic understanding of billing ICD 9 & ICD 10 codes for claim submission
- Conduct bi-weekly face to face meetings and presentations with providers documenting discussions, issues, attendees, and action items researching claims issues onsite and routing to the appropriate party for resolution
- Advise provider on health plan and Federal/State related healthcare law changes and updates
- Assist with Provider contractual policies and procedure interpretation by researching, analyzing and resolving complex problems relating to claims, appeals, grievances and eligibility
- Update provider orientation and training materials based on Federal, State, and/or Health Plan health program changes
- Prepare, distribute, and analyze State required Provider Network Adequacy report(s) to management team and healthcare quality auditor improvement vendor company
- Create and develop management level reports and dashboards on daily department operations
0-5 years of experience
- Provide accurate and timely customer service to our through routine telephone inquiries and written correspondence both simple and complex
- Review and resolve simple and complex provider issues, claims questions, provider contract issues, and patient inquires which directly impacted our provider’s daily business practices.
- Communicate claim status, enrollment/membership and benefit policy and procedures to providers
- Maintain excellent quality since hired
- Participate with Showing /Buddy sessions with new hires and seasoned reps that had refresher training. Demonstrated ways to navigate and see how all applications work.
- I have been crossed training in several lines of business such as IPP, ASO, State PPO and Commercial.
- Participated in the process of hiring new service representatives
0-5 years of experience
- Loaded providers by NPI number to the correct Tax Id Number in system
- Verified information of providers to ensure payment was mailed to correct address
- Customer Service
- Assist members in locating providers for specific needs or in certain areas
- Customer service
- Other duties as assigned
0-5 years of experience
- Calling providers who have inquired about joining the network
- Fielding provider contract and claims issues
- Work in conjunction with Network Account Managers in regards to physician groups
- Answer provider inquiries via email, telephone, and written correspondence
- Contract new providers to an existing provider group
- Research and assists in the resolution of regulatory inquiries and/or DOI complaints
- Facilitate the resolution of credentialing issues and coordinates, and complete external and internal termination notification requirements
0-5 years of experience
- Serves as liaison between [company name] and provider community in multiple counties.
- Responsible for physician recruitment and contracting, database management and Access and Availability audits.
- Investigate and respond to inquiries from Grievance and Appeals, Customer Service, Credentialing, Claims and other departments.
- Completes needed record retrieval for state and government audits.
- Identify network gaps and work with Network Development team to fill deficiencies.
0-5 years of experience
- Recruit and contract physicians to participate with ACO, CI risk and non-risk contracts.
- Maintain strong relationships with 500+ assigned providers.
- Provide provider orientation and education on contracts policies and procedures.
- Research and resolve all provider claim, referral, credentialing, and contracting issues
- Negotiate rates and contracts with out-of-network providers as needed.
- Collect provider credentialing information and insure CAQH is current.
- Visit bi-annually the top 50 primary care and specialist physicians.
- Provide training and guidance to new Provider Relations Representatives.
- Attend and participate in Local Leadership Council (LLC) meetings and serves as a liaisons between PHP leadership, Physicians, and LLC members.
0-5 years of experience
- Maintained relations with providers to ensure the partnership with the health plan was successful.
- Processed provider credentialing applications in accordance with accreditation standards, regulatory requirements and policies and procedures.
- Accountable, on a monthly basis, to confirm each provider that was due for recredentialing had the proper licenses, insurance, work history, etc. in order to maintain the relationship with the provider and the health plan.
0-5 years of experience
- Assist in building and nurturing positive relationships between the health plan, providers and practice managers.
- Identify HEDIS care opportunities and provider services to prioritize member needs in seven counties in the NJ Market.
- Familiar with UnitedHealthcare, Oxford, Medicare and Medicaid lines of business, policies and procedures.
- Analyze and optimize healthcare according to Medicare STARS program and National HEDIS Regulations.
- Investigate both routine and non-standard provider related problems and issue resolution, demographic, clinical and market incentive
- Independently prioritize and organize own work to meet departmental and organizational deadlines.
- Communicate effectively with physicians and their office staff as well as with both the Provider Advocate and ACO Teams.
- Provide support to ensure complete contract compliance. Understands and works in accordance with HIPAA guidelines and rules.
- Knowledge of CMS reimbursement methodologies in terms of The Resource-Based Relative Value Scale (RBRVS).
6-10 years of experience
- Provide professional and responsive customer service to dental providers
- Answer all provider inquiries regarding claims and system errors
- Create and update provider records in FACETS and Salesforce systems
- Verify and update provider demographic information
- Work Outbound call projects and Provider Directory Audit projects
- Train team members and new hires on current processes
- Create Policies and Procedures as needed
- Utilize necessary resources and navigate systems efficiently to accurately verify information for providers
0-5 years of experience
Provider Relation
- Assists in the maintenance of provider manual.
- Maintains records in accordance with corporate policy and/or regulatory requirements.
- Assists in annual provider network availability and accessibility standards and provider satisfactions surveys.
- Participate in education programs for providers and their staffs regarding new provider systems.
- Provides face-to-face meeting with providers to address communication issues and concerns.
- Manages electronic claims submissions and reception checks from CMS and other issuance agencies.
- Assists project development.
- Assists providers to address meaningful use concern and PQRS reporting.
- Sales EMR services.
- Responses and resolves customer services inquiries and issues regarding EMR systems.
0-5 years of experience
- Acts as the primary contact for assigned groups, Health Centers and Individual providers.
- Meet with community based physicians and physician groups on a regular basis to identify problems and/or concerns; maintain relationships with key contacts to ensure and support mutually beneficial relationships and ongoing collaboration. Giving presentations to new and existing providers and provider groups.
- Work with internal staff to resolve provider issues with regards to billing, payments, denials, authorizations and other interactions.
- Manage the provider relations mailbox; triage inquiries, facilitate resolution of incoming requests and/ or forward such requests as appropriate.
- Follow up with providers regarding confirmation of changes, and maintaining appropriate documentation.
- Assist Network Development in ongoing identification of providers need for network completion or expansion (physicians, ancillary providers, community agencies, advocacy groups, etc.) And assist Network Development in recruitment of providers.
- Distribution and collection of provider contracts, preparation of complete contracts/application packets for credentialing process and maintain ongoing practioner credentialing efforts for large providers.
- Function as a designated responder for provider relations call line- respond to calls on eligibility, authorization and benefit questions.
0-5 years of experience
- Coordinating completion of credentialing
- NPI applications
- Draft letters of interest to Health Plans
- Maintain rosters for national contracts
- Responsible for database accuracy
- Issue resolution with the health plan
- Claims resolution
- Department of Labor enrollment
- Tricare enrollment
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Provider Relations Representative
Last edited by: Gabriela Barcenas, CONTENT STRATEGIST -
Gabriela Barcenas
CONTENT STRATEGISTGabriela is a Certified Professional Resume Writer (CPRW) and career adviser. With 10 years of digital media experience and five years of resume writing expertise, her publication history includes fashion, education, travel, social justice, equitable design and career advice.
