The Provider Relations Representative takes responsibility for building and cultivating a relationship with users and ensures a high level of customer service. A well-drafted Provider Relations Representative Resume lists the following tasks and duties – providing professional customer service, identifying ways to enhance processes, providing support for other projects in the company, responding to inquiries from providers, using specific software, negotiating contracts, reviewing and revising contracts, maintaining provider databases, handling complaints from providers, developing letters of agreement, maintaining provider documentation files and performing financial analysis pertaining to provider contracts.
The most sought-after skills and qualifications include the following – technical skills, relationship management, conflict resolution skills, interpersonal abilities, strong communication skills, the ability to remain polite while dealing with angry providers; and negotiation skills. The ideal candidate for this post should depict on their resume a bachelor’s degree in business or other related fields.
Summary : Results-oriented professional with twelve years of proven success in contract management, provider service, training, and medical claims/billing. Specific knowledge in Business Administration with a concentration in Healthcare Management.
Skills : Medical Claims Processing, Training, Data Analysis, Medical Claim Appeals Processing, Document Composition.
Description :
Acted as the liaison between SHP and participating providers by responding to provider needs and inquiries, and educating providers and their office staffs.
Conducted service calls as requested by the provider and addressed issues that may have had negative impacts on SHP through in-servicing/training providers who demonstrate practice patterns that are not cost-effective to the organization.
Scheduled, coordinated and conducted new provider orientation/training for all six SHP products.
Maintained contract requirements by completing appropriate forms and obtaining attendance logs for each visit.
Performed in-services/training, with frequency as detailed by department policy, for providers for the purpose of communicating policy changes.
Educated providers about provider manuals, directories, and on-line provider resource tools.
Coordinated with internal departments such as claims, medical management, provider services, credentialing, and EDI departments to investigate provider complaints related to care and/or services provided, and access.
Experience
7-10 Years
Level
Management
Education
Business Administration
Sr. Provider Relations Representative Resume
Summary : Sharp, hardworking, capable with experience in clinical research, managed care, and health insurance. Detail-oriented multi-tasker, able to work independently or with a team, and able to lead. Articulate communicator with knowledge of provider networks, charge assignment billing grids, claim denials, billable procedures, credentialing providers, and training medical personnel. Skilled at learning new concepts quickly, working well under pressure, and an efficient decision-maker.
Managed physician accounts for Medicaid managed care and commercial insurance companies.
Trained physicians and medical personnel on claims progressing, obtaining authorization, member products, computer programs, and insurance company history.
Account manager for private physicians in 17 cities, 14 hospitals, and 3 provider networks.
Conducted physician site visits and screen providers for health care plans Trained small and large groups of medical personnel on member plans, computer programs, obtaining authorization, and claims processing.
Recruited Medicaid and Medicare physicians.
Resolved physician's grievances and investigated denied claims.
Trained physicians and medical personnel on claims progressing, obtaining authorization, member products, computer programs, and insurance company history.
Experience
7-10 Years
Level
Senior
Education
Bachelor's In Corporate
Jr. Provider Relations Representative Resume
Objective : Contract Negotiations and Audit/Reconciliation for Health Plans, Networks, Multi-Practices, and Billing Departments with an emphasis on leadership and growth.
Skills : Customer Service.
Description :
Liaison between UHN and health care providers for purposes of recruiting, contracting, retaining, evaluating, maintaining and supporting UHN networks.
Analyze, monitor and modify the provider contracts to appropriate fee schedules.
Negotiate and re-negotiate rates based on a thorough analysis of the network to insure consistent competitive rates.
Interact as primary contact to the provider community consisting of primary and specialty physicians and their staff to identify concerns and provide necessary training and continuing education.
Identify network gaps and recruit qualified providers in accordance with client/payor/network needs.
Recruitment initiatives to include mailings, follow up and tracking of results.
Detail oriented and knowledge of various fee schedule methodologies, including but not limited to CRVS, RBRVS, per diems and global discounts Gallup Q-12 Representative for Universal Health Network.
Experience
2-5 Years
Level
Junior
Education
Diploma
Lead Provider Relations Representative Resume
Summary : To obtain an executive position in Health Care Management, Sales or Marketing, where can utilize skills for community relations, resource coordination, sales, and economic development.
Skills : Healthcare, Provider Relations, Training, Training & Development, HEDIS measures, Business Development.
Description :
Served as the liaison to the Primary Care Association to obtain and correct any issues that may arise with the state's community health centers.
Provided oversight of entry or change of provider related database information request through PDM.
Educates providers regarding policies and procedures related to referrals and claims submission; web site education, EDI solicitation and problem-solving.
Conducts reviews of provider manuals and policies and procedures to update providers of new health plan protocols.
Authored change request and oversee through testing and completion.
Conducted daily field visits with community health centers to provide outreach and resolutions to provider inquires.
High energy, self-starting individual who has proven a success and will thrive in a team environment.
Experience
7-10 Years
Level
Management
Education
General Education
Provider Relations Representative III Resume
Headline : Experienced provider relations professional with a successful career in the healthcare industry. Excellent time management, team organization and customer service skills. Excel in developing strong relationships with physicians, their administrative staff and ancillary providers.
Skills : Communicating effectively in a team environment.
Description :
Responsible for servicing all contracted providers within Miami-Dade County.
Responsible for completing new provider orientations/in-services with all applicable product lines within given timelines.
Conducts site inspection evaluation visits to service providers, resolve issues, educate staff/providers on policies, collect credentialing information, and review HEDIS information.
Achieves call reach and frequency goals to establish consistent and strong relationship with provider offices.
Provides oversight on inquiries and claims issues and follows up with providers to ensure problems have been resolved.
Supports regional Network Improvement Plan targets by providing utilization reports, pharmacy profiles, ER contingencies, Frequent Flier Reports and other analytics available to improve/maintain regions.
Ensure that all documentation received for new/existing providers, demographic updates, terminations, credentialing and re-credentialing is accurate and complete for submission.
Reviews and submits incoming and outgoing paperwork, including directory updates, provider credentialing applications, member move forms and other related forms.
Experience
5-7 Years
Level
Executive
Education
Associate Of Science
Provider Relations Representative II Resume
Summary : An enthusiastic and motivated Healthcare Leader and Project Manager. Extensive experience providing training for large physician groups, and mentored and trained new team members.
Skills : Management, Quickbooks, Billing, Customer Service, Data Entry, Excel, Notary Public, Office Management, Receptionist, Medical Billing.
Description :
Provide education about policy, claims, authorizations, reimbursement, and enrollment through workshops, in-services and face to face visits Perform routine audits on medical records located in Medical practices.
Perform routine site reviews at Medical practices to ensure that Medical providers' facilities are within state standards.
Perform recruitment and retention of medical doctors, dentists, and other medical providers for the Texas Medicaid program.
Contract Compliance Officer Perform routine audits of medical records located in medical and dental practices, clinics and hospitals.
Perform routine site reviews at Medical practices to ensure that medical providers' facilities are within state standards.
Provide education to medical staff on how to correct deficiencies found.
Provide education to Medical providers on changes to policy Business Analyst Research and adjust medical policies, rates, procedures, and cost reports for the Texas Medicaid program.
Experience
10+ Years
Level
Senior
Education
Associate Of Science
Provider Relations Representative I Resume
Summary : A position as a Licensed Vocational Nurse with a facility that will allow me to correspond to employer competently and give the utmost level of ease, respect and care to patients.
Skills : Excel, Microsoft, Power Point, Publisher, Visio, Adobe.
Description :
Responsibly maintain working relationships with a network of physicians, hospitals, facilities, and physician groups.
Assist in the recruitment and credentialing process of new physicians and groups.
Resolve problems and educate providers of new protocols, policies, and procedures.
Maintain accurate and current provider databases relating to provider facilities and physician information.
Assist with policy and procedure interpretation, assessment of training needs and development and implementation of training programs.
Actively negotiate individual physician agreements, which include reviewing, preparing draft agreements.
Recruit and contract individual providers who meet established selection criteria to assure adequate geographic and specialty coverage; including making recommendations for retention or delisting of physicians.
Research and Resolve administrative problems, claim issues affecting network physicians, patients', healthcare plans, physician groups, facilities and hospitals within contracted guidelines.
Experience
7-10 Years
Level
Consultant
Education
Bachelor Of Science
Provider Relations Representative I Resume
Summary : Looking for an exciting position with a great company, in which enjoy and look forward to each day. Providers are responsible for the delivery of our products to our customers. Providers are responsible for ensuring the quality and availability of our products, and that they are always meeting the requirements of our customers.
Skills : MS Office, MS Excel.
Description :
Maintained and enhanced existing provider relationships by leveraging health plan knowledge to address and resolve a variety of provider inquiries and issues.
Worked closely with the Sales Team to pursue and establish strategic partnerships with a wide variety of healthcare providers to recruit them to the plan.
Utilized policy, procedure, and professional experience to effectively respond to questions regarding contracting, fee schedules, claims payments, co-pay structures, and plan types.
Collaborated across departments to quickly address action items and implement provider education and communication tools.
Maintain provider accounts to ensure accurate data regarding billing information and practice locations.
Assisted with Sales Support Key highlights Appointed as Contract Negotiator.
Expanded the firm's client base by identifying, pursuing, and recruiting a wide variety of healthcare providers to the plan.
Composed letters of agreement (LOA) for physicians and facilities.
Experience
7-10 Years
Level
Consultant
Education
BA In General
Provider Relations Representative/Analyst Resume
Summary : Versatile professional administrative assistant adept at providing customer support, streamlining office operations and handling multiple projects simultaneously. Expert at optimizing billing processes, maintaining databases and creating high-impact proposals committed to fostering interdepartmental collaboration.
Skills : Management, Customer Service, Negotiation, Data Entry, 10-Key, Documentation, Excel, Filing, Fax, Research, Receptionist, Sales, Typing, Team Building, Video Editing, Word.
Description :
Educated, monitored, analyzed, and interacted with providers regarding BCBS policies.
Provided comprehensive customer service and assistance to clientele, including dispensing detailed information to inquiries regarding the application process.
Recorded data accurately for processing shipped records.
Coordinated and communicated with all departments within the BCBS System by providing excellent customer support.
Interacted with providers and claimants via mail or telephone to correct claim form errors or omissions and investigate questionable entries and independently review moderate complex claims.
Facilitated effective channels of communication daily by providing oral and written guidance relating to inquiries and processing procedures.
Used numerous statistical filing systems to enter and post data as it relates to the customer bill/account.
Efficiently and productively used medical terminology and coding knowledge to accurately process claims to increase productivity and improve the daily workflow.
Headline : Business professional with 18+ years' experience in healthcare field with contracting, credentialing, fiscal and budgetary management experiences. Proven skills in contracting, analytics, metrics and reporting, project development, and operational improvements.
Skills : Experience With Microsoft Office Tools, Including Project, Visio, And Share Point.
Description :
Negotiated and finalized designated contracts, including but not limited, to high volume hospital contracts.
Maintained Access database of all contracts and specified applications sent to prospective and new providers Assisted in high volume IPA, hospital systems or tertiary facilities and other key contracts.
Conducted weekly meetings with the contract analyst department regarding status of contracting and integration.
Negotiated and processed out of network letter of agreements identified by Health Services Management Department.
Performed all fees schedules/contacts analysis and negotiations for physicians and facilities including laboratory services.
Reviewed workflow processes, obtained practice management system and contracting information and set customer expectations about the implementation process.
Contacted new providers and ensured that credentialing applications were submitted.
Conducted site reviews and documented information which is integrated to the proper department.
Objective : Business professional with 18+ years' experience in healthcare field with contracting, credentialing, fiscal and budgetary management experiences. Proven skills in contracting, analytics, metrics and reporting, project development, and operational improvements. Possesses a high level of professionalism, learning agility, customer service standards, and communication skills.
Skills : Excel, Microsoft, Power Point, Publisher, Visio, Adobe.
Description :
Negotiate and maintain effective and efficient systems and procedures for recruiting, and contracting with a full range of health care providers.
Work directly with providers and professionals to develop efficient health care delivery, resolve issues, and provide continued provider support.
Departmental resource and consultant to the executive medical team in credentialing processes and procedures to ensure regulatory compliance.
Subject matter expert interpreting credentialing policies and regulations.
Conduct financial research and analysis relating to physician compensation rates.
Financial and budgetary analysis related to the oversight, tracking, and monitoring of program and fiscal management.
Revamped reporting mechanism used for credentialing evaluations by a board of physicians.
Responsible for continued program oversight and collaboration with team members to ensure compliance with documentation requirements used in developing these reports.
Experience
2-5 Years
Level
Junior
Education
Bachelor Of Science
Provider Relations Representative Resume
Summary : Dear Human Resources, Interested in the position. Maturity, people skills, respect and experience the position requires. In all positions an extreme amount of responsibility and organization and attention to detail has been key.
Skills : Excellent Communication Skills.
Description :
Responsible for managing company's provider relations functions including database maintenance, train new staff, directories, communications, and special projects.
Perform quality reviews of Spanish translated documents.
Assist claims department to research information related to non-participating provider claims within a one-day turnaround.
Conducted company-wide, after-hours audits of staff compliance with HIPAA requirements and prepared initial report for Privacy Officer.
Assist Finance department in researching discrepancies between provider and facility information and IRS records.
Participate in International Collaborative Efforts (ICE) claims standardization and provider profiles meetings.
Work with medical management department (nurses, pharmacist, and medical doctors) to keep with NCQA/HEDIS requirements.
Collaborate with compliance/legal department to keep with DMHC standards and help with forming internal processes for provider relations.
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