A Provider Resolution Specialist is responsible for coordinating with vendors to resolve all account issues and escalating all unresolved issues to management. The major duties and responsibilities are listed on the Provider Resolution Specialist Resume as – coordinating with external vendors to solve all issues and providing an appropriate response to all collection hotline complaints; performing research for all complaints and recommending required action, managing all overdraft situations, and maintaining records of all received letters from borrowers, solving all borrower issues and preparing all required documents for resolution, monitoring all order associate issues and recommending resolution for all call-center representatives, and preparing all reports for resolutions provided and maintaining records of all status.
A well-written resume for this role should focus on skills such as conflict resolution skills, good listening and communication skills; computer literacy, and customer service skills. Most of those applying for this role have a college education and receive on-the-job training.
Headline : As a Provider Resolution Specialist, responsible for Initiating data entry of provider-related demographic information changes overseeing testing and completion of change requests for the network, and also Investigating, resolving, and communicating provider claim issues and changes.
Skills : Multitasking, MS Office.
Description :
Ensured to provide excellent customer service through phone, in a timely and accurate manner.
Served as liaison between provider support team, management, and provider to improve provider service and business productivity.
Analyzed provider complaints, Claims, or requests and provide appropriate corrective actions.
Assisted directly or route provider to the appropriate personnel for assistance.
Ensured provider satisfaction by meeting provider needs in a courteous and timely manner.
Tracked, followed up, and resolved the provider's outstanding issues in a timely fashion.
Developed provider service programs in order to provide outstanding service.
Experience
5-7 Years
Level
Executive
Education
GED
Provider Resolution Specialist Resume
Summary : To obtain a Provider Resolution Specialist position where I can utilize my skills and experience to become a part of a successful team, all while achieving my goals.
Skills : Microsoft Office, Communication Skills.
Description :
Provided providers with information on eligibility, and benefits verification.
Performed claim research as well as provided claim status.
Interpreted complex and sensitive information while following HIPPA guidelines.
Answered incoming calls and demonstrate exceptional customer service.
Performed data entry, material requests, and online setups.
Researched billing codes for accuracy.
Handled intake calls to establish prior authorizations for patients procedures whether inpatient or outpatient.
Experience
7-10 Years
Level
Management
Education
High School Diploma
Provider Resolution Specialist Resume
Summary : Provider Resolution Specialist with 10+ years experience; skilled in Medical Terminology, and medical insurance processes. Leading Coworkers Quality Management Attention to detail Excellent oral and written communication skills Strong computer and phone skills: word, excel, access Medical Terminology Electronic Medical Record Call Center Process/Technology Medical Insurance Processes Knowledge of products to include HMO, PPO.
Skills : Customer Service, Customer Relationship Management, Multi-Line Phone System, Problem Resolution, Process Improvement, Leadership Development, Leadership Development.
Description :
Taken incoming calls from members, providers, and other entities related to policies, claims, and plan processes for performance guarantee groups.
Accurately responded to all concerns and/or questions.
Researched claim inquiries or issues and determined action required.
Accurately documented calls and process any adjustments or changes required to the member's record.
Adhered to all HIPAA and company guidelines.
Acted and responded professionally to any situation that may occur during the call.
Responsible for supporting the Health Plan and mainlining positive relationships with providers, key stakeholders, business units, departments, and/or divisions within the assigned area.
Experience
10+ Years
Level
Senior
Education
High School Diploma
Provider Resolution Specialist Resume
Summary : Highly motivated business and office management professional with over 15 years of experience in results-driven environments. Strong ability in creating and leading dynamic teams. Demonstrated knowledge in both human resource management and recruiting with a focus on the managed healthcare industry.
Answered CSR claim inquiries via live transfer and resolves issues in real-time.
Thoroughly researched post-payment claims and takes appropriate action to resolve them within turnaround time requirements and quality standards.
Acted as a liaison between internal departments on data gathering and problem-solving while investigating problems of an unusual nature in the area of responsibility.
Presented proposed solutions in a clear and concise manner.
Processed claim adjustment request in Xcelys queue routing system and provides the appropriate level of coaching, analysis, and resolution to CSR.
Assisted team members often guiding them to the appropriate resolution of more complex and difficult cases.
Identified root cause issues to ensure enterprise solutions and communicated findings as needed.
Experience
10+ Years
Level
Senior
Education
Diploma
Provider Resolution Specialist Resume
Objective : As a Provider Resolution Specialist, responsible for Educating providers regarding policies and procedures related to referrals and claims submission, website usage, EDI solicitation, and related topics Performing provider orientations and ongoing provider education, including writing and updating orientation materials.
Reviewed transparent quality and utilization reports along with specific patient and payor data with network physicians and office staff and connects practice to relevant support for performance improvement.
Supported low-performing physicians through performance improvement process in collaboration with AHPN Medical Director and assist leadership and AHPN governance structure to evaluate high, medium, and low performers in the network.
Used knowledge to help connect key concepts and expectations, ultimately presenting the Regional Market CIN, and/or affiliated payer networks/health plans, in a manner that is simple for providers to relate to.
Regularly rounded to communicate messages about the value of solutions, strategies, performance/incentive models, policies, procedures and timely issue resolution.
Onboarded providers for Provider Networks and affiliated payer networks/health plans to ensure provider is informed and engaged related to essential information.
Facilitated practice change management in regards to emerging trends related to population health initiatives, reimbursement models, patient satisfaction, customer outreach, panel growth, and provider performance with quality and efficiency metrics.
Actively participated in continuing education topics and suggests topics or items based on conversations occurring in the field or based on other perceived gaps in education.
Experience
2-5 Years
Level
Executive
Education
High School Diploma
Provider Resolution Specialist Resume
Objective : Provider Resolution Specialist with 4+ years of experience in Performing duties to act as a liaison between providers and corporate teams including investigating and resolving provider claims issues, Performing training, orientation and coaching for performance improvement.
Skills : Microsoft Word, Powerpoint, Word Processor, Fax, Copy.
Description :
Taking escalated calls in regards to claim processing Floor walking for team assistance inputting notifications for approvals Medicare and retirement calls Administered benefits and eligibility information for numerous clients.
Provided excellent customer service to customers regarding medical insurance claims.
Assisted medical staff with insurance information regarding patients.
Use of written and verbal skills in a fast paced environment.
Typed 45+ words per min.
Assisted with special projects as assigned or directed.
Determined what requirements are needed prior to patient's procedures.
Experience
2-5 Years
Level
Junior
Education
BS In Mass Communications
Provider Resolution Specialist Resume
Objective : To obtain a full time position with an established company that enables me to utilize all of my skills and offers continuous growth within the company. Professional Licences Certificate of completion in Medical Billing - earned from At Home Professional's.
Skills : Human Resources, Microsoft Office.
Description :
Served as liaison to providers (including physicians, hospitals) and internal departments at the health plan.
Responsible for performing activities designed to establish and maintain positive and productive relationships with United Healthcare network providers for Medicaid and Medicare products.
Responded to inquiries from providers regarding benefits, claim resolution, appeal status, and notification.
Researched and responded to written inquiries from providers and document all contacts in appropriate system per Plan.
Provided expertise and assistance relative to provider billing and payment guidelines consistent with United Healthcare policies and procedures.
Provided follow up and intervention relating to provider complaints, thereby ensuring that the complaint process is appropriately handled within established time frames.
Ensured that provider relationships with the Plan are positive and productive.
Experience
2-5 Years
Level
Executive
Education
High School Diploma
Provider Resolution Specialist Resume
Objective : Dedicated Provider Resolution Specialist motivated to maintain customer service satisfaction and contribute to company success. Energetic, results-driven professional who's advanced In customer service. Highly skilled in performing office support duties such as providing information to the public, receiving payments and addressing customer complaints.
Skills : Microsoft Word, Scheduling Appointments, Cashiering, Housekeeping, Answering Phones.
Description :
Responsible for answering escalated claim adjustment requests and resolving issues received through transferred provider phone calls.
Acted as a liaison between internal departments on data gathering and problem solving.
Processed claim adjustments and provided appropriate level of coaching, analysis and resolution to providers.
Evaluated and reported financial payment accuracy on claims.
Logged, tracked and documented all issues utilizing online systems and procedures while on call with providers.
Resolved critical errors related to rejections, coding denials, claims processing and pricing.
Assisted with special projects.
Experience
2-5 Years
Level
Executive
Education
BS In Communications
Provider Resolution Specialist Resume
Headline : Highly qualified Provider Resolution Specialist with experience in the industry. Enjoy creative problem solving and getting exposure on multiple projects, and I would excel in the collaborative environment on which your company prides itself.
Skills : Retail, Computer Skills, Communication Skills, Customer Service, Problem Solving, Leadership, Perseverance, And Motivation. Work Under Pressure And Responds Well To Constructive Criticisms.
Description :
Answered incoming phone calls from health care providers (i.e. physician offices, clinics) and identify the type of assistance the provider needs (i.e. benefit and eligibility, billing and payments, authorizations for treatment and explanation of benefits (Claims).
Resolved issues on the first call; navigated through the appropriate computer system(s) to identify the current status of the issue and provided appropriate response to caller.
Delivered all information and questions in a positive, conversational and compassionate manner to facilitate developing a relationship with the provider, while providing the best customer service experience possible.
Completed the documentation necessary to track provider issues and facilitate the reporting of overall trends.
Met the performance goals established for the position in the areas of: efficiency, call quality, provider satisfaction, first call resolution and attendance.
Solved problems systematically using sound business judgment and follow through on commitments.
Assisted in training peers on improving customer support service.
Experience
5-7 Years
Level
Executive
Education
GED
Provider Resolution Specialist Resume
Objective : Seeking a position in which different skills and work experience can be obtained in the Health Information Management field. I am looking to work with a company in which I can maximize my skills and continue to progress in Health Information Management. I am looking for a company that is willing to allow me to apply everything that I have learned about HIM while receiving my degree and working in the field.
Skills : Team Management, Coaching & Developing, Operations.
Description :
Responsible for assisting medical, dental, vision and pharmacy providers telephonically.
Provided benefits and eligibility information.
Responsible for reviewing claims and returning incorrectly adjudicated claims for reprocessing.
Reviewed and assisted with prior authorizations.
Responsible for assisting providers with appeal submission and status.
Provided internal assistance to both Member and Provider Services representatives for the National Call Center regarding claims issues, Policy and Procedures, and also Plan Benefits.
Performed correct documentation, and issue tracking.
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