Provider Relations Rep Resume Samples
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Provider Relations Rep Resume Samples
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SN
S Nolan
Shanie
Nolan
20781 Ryan Crescent
Detroit
MI
+1 (555) 451 7088
20781 Ryan Crescent
Detroit
MI
Phone
p
+1 (555) 451 7088
Experience
Experience
New York, NY
Provider Relations Rep
New York, NY
Zemlak, Hudson and Koelpin
New York, NY
Provider Relations Rep
- Monitor provider and facility adequacy, recruitment, education, respond to and document all inquiries. Conduct follow-up activities for behavioral health providers and facilities
- Identifies and resolves provider issues by researching causes and working with Beacon’s clinical, operations and IT teams
- Coordinate activities with internal departments and external partners to optimize customer service to network providers, non-network providers, facilities and internal customers
- Responsible for utilizing software programs to track site visits, daily activities, tasks for self and teammates (when necessary), in addition to other functions. Produce report as requested by manager. Become proficient in and utilize software. Current systems include Marketware / MD-Staff
- Facilitate provider issue resolution. This may include utilizing internal Presence Health Partners teams and follow-up with providers to close the loop of issues and concerns. Issue resolution includes, but is not limited to, general education, claims, billing, referrals, etc
- Works with Manager of Provider Relations to plan and present provider events, including Provider Advisory Councils and Provider Appreciation Breakfasts in all markets
- Execute strategies relating to the development or enhancement of provider networks. This includes, but is not limited to defining provider targets and executing contracting efforts
Boston, MA
Provider Relations Rep-ne
Boston, MA
Toy, Rosenbaum and Bartell
Boston, MA
Provider Relations Rep-ne
- Verifies Health Plan Provider Directory
- Keep informed of current health/managed care information
- Scheduling, leading and reporting on provider site visits
- Responding to provider calls on the Provider Services Line queue as well as emails, voicemails and faxes seeking assistance
- Assists Manager and Team Lead with quality assurance measures
- Provide administrative support to the Provider Relations team. This would include but not limited to, following up on all return mail, follow-up on provider change request, conduct demographic outreaches, assist with researching and locating providers for recruitment into the network, as well as, sending providers educational materials and yearly fee schedule
- Maintain up to date knowledge of the contract and company policies, processes, and programs. Be familiar with any contract changes that impact behavioral health. Answer provider/facilities questions regarding contract policies and procedures
present
New York, NY
Senior Provider Relations Rep
New York, NY
Dietrich, Glover and Labadie
present
New York, NY
Senior Provider Relations Rep
present
- Assures compliance with respective contracts. Researches, analyzes and resolves claims, benefits, issues and authorization inquiries within delegated authority
- Influences membership growth and retention through the provider offices
- Monitors provider database of current data relating to provider and physician information
- Ensures provider directories are accurate
- Investigates compliance issues, identifies root cause, trains provider office staff on correct procedures, and provides written report of findings and recommendations
- Meets on a regular basis in person or by telephone with assigned key provider groups to cultivate and strengthen relationships. Documents office visits and provider issues on shared drive log
- Supports the retention of providers by participating in meetings, conducting research, and supporting provider credentialing
Education
Education
Bachelor’s Degree in Health Services
Bachelor’s Degree in Health Services
Columbia University
Bachelor’s Degree in Health Services
Skills
Skills
- Ability to work proficiently with Microsoft Word
- Possess the ability to build a strong working relationship and maintain open communication with providers so that issues may be raised in a proactive manner
- Ability to be careful and thorough about detail
- Basic Microsoft Office knowledge
- Proficiency in Microsoft Word & Excel
- Analytical and problem solving ability
- Ability to communicate and exchange information
- Ability to comprehend and interpret documents and data
- Strong understanding of managed care and healthcare operations
- Demonstrated ability to interact with mental health, substance abuse and employee assistance program providers
1 Provider Relations Rep resume templates
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1
Provider Relations Rep Resume Examples & Samples
- Minimum Knowledge and Education: Preferred Bachelor's degree in Health Services, Public Health or related field desirable
- Minimum Work Experience: One to three years minimum experience in a health care organization preferably with specific knowledge of Managed Care including Health Plan guidelines, policies/procedures, and reimbursement as well as experience in a provider service environment
- Skills, Abilities: Knowledge of managed care environment and financial models in the market. Computer skills - proficiency with Microsoft office products, especially Word, Excel, and Power Point. Medical terminology, typing skills. Must have proficient verbal and written communication skills and be able to perform highly effective formal presentations. Demonstrate excellent interpersonal skills necessary to interact effectively with customers of all levels, including physicians and administrators. Capable of analyzing information related to provider issues and effectively problem solve. Effective organizational skills and ability to prioritize multiple demands while maintaining exceptional responsiveness to customer inquiries
2
Provider Relations Rep-columbia Resume Examples & Samples
- Conducts site visits to service providers to provides education on policies and initiatives, resolve issues, educate staff/providers on policies, collect credentialing information and review HEDIS information. Addresses RxEffect, P4P, Medical Home, Cultural Competency, FWA, open/closed panels, ADA, PaySpan, ER overuse, et al
- Provides oversight of delegated functions, as applicable
- Performs special projects as assigned
3
Provider Relations Rep-manatee Resume Examples & Samples
- Provides oversight on claims issues. Follows up with providers accordingly
- Ensures contract SLA’s are met, such as meeting with PCP’s and Specialists on a monthly, quarterly, or annual basis to address provider panels, after hour’s availability and EMR meaningful use
- Partners with finance to identify Medical Expense Initiatives to take actions necessary to successfully complete those initiatives, and assess progress on achieving financial goals
- Intermediate Demonstrated organizational skills
4
Provider Relations Rep Resume Examples & Samples
- The Provider Relations Representative I work on behalf of State Medicaid agencies to recover payments from the provider(s) who should have billed Medicare for the service instead of Medicaid
- Respond to incoming phone calls, e-mails, and faxes from customers with regard to mailings, cycles, or other functions performed by the service center
- Medicaid/Medicare experience
5
Senior Provider Relations Rep Resume Examples & Samples
- Ensures provider directories are accurate
- Assists management in tracking, trending and reporting on provider recruitment and retention
- Provides support on special projects and performs other duties as needed or assigned
6
Provider Relations Rep Resume Examples & Samples
- Initiates phone calls to customers, (providers/pharmacies/patients/carriers etc) to confirm receipt of mailings, and to request action
- Provides timely response and resolution for all provider initiated inquires (phone calls, emails or faxes)
- Reviews and analyzes documentation and claim data to determine validity and proper action
- Updates accounts receivable system with denial and group information
- Assists with high priority special projects
- Ability to work proficiently with Microsoft Word
- Ability to organize well
- Ability to demonstrate a customer service orientation
- 2+ years’ experience as an examiner/processor with exposure to medical terminology and claim processing experience in Commercial Insurance or Government Programs required
- 2+ years previous experience in a claims customer service environment OR
- 2+ years of answering inbound calls regarding claims processing
7
Provider Relations Rep Resume Examples & Samples
- Assists in the identification of service level gaps and works with Manager of Provider Relations and Contract Managers to address recruitment opportunities
- Actively outreaches and trains providers to increase the rate of electronic transactions through training and education
- Responds to provider calls on the Provider Services Line queue as well as emails, voicemails and faxes seeking assistance
- Works with Manager of Provider Relations to plan and present provider events, including Provider Advisory Councils and Provider Appreciation Breakfasts in all markets
- 2-3 years Customer Service Experience
- 2-3 years Claims Experience
8
Provider Relations Rep Resume Examples & Samples
- Possess the ability to build a strong working relationship and maintain open communication with providers so that issues may be raised in a proactive manner
- Must maintain up to date knowledge of TRICARE and ValueOptions policies, processes, and programs. Be familiar with any contract changes that impact behavioral health. Answer providers/facilities questions regarding ValueOptions and TRICARE policies and procedures
- Act as a liaison between providers, facilities, TRICARE partners and other ValueOptions departments to facilitate communication, resolve inquiries and provide education. Ensure the appropriate use of the chain of command
- Maintain network adequacy and identify network needs by conducting access surveys to include recruiting additional providers and facilities, as needed, based upon routine monitoring of network adequacy, beneficiary complaints and access to care issues within assigned geographic area
- Responsible for monitoring provider and facility network adequacy, recruitment, education, respond to and document all inquiries. Conduct follow-up activities for behavioral health providers and facilities within assigned region
- Ensure demographic information and facility POCs are accurate by verifying during each provider/facility contact. Forward all other demographic changes to the Provider File section
- Receive mentoring on facilitating and conducting provider/facility education to assigned network providers according to segmentation criteria. Schedule and conduct welcome call to providers no later than 30 days from effective date and provide ongoing education as needed
- Provide administrative support to the PRR team. This would include but limited to following up on all return mail, follow up on provider change request, and updatingNetwork Connect (NWC), conduct demographic outreaches, assist with researching and locating providers for recruitment into the network, as well as, sending providers educational materials and yearly fee schedule
- Maintain punctuality and regular attendance. Give proper notification when unable to meet this requirement
- Complete research and other special projects and duties as assigned
- Comply with all HIPAA regulations. Comply with established HIPAA guidelines and reports any possible violations immediately to his/her immediate supervisor and/or the designated HIPAA Officer
9
Provider Relations Rep Resume Examples & Samples
- Assists Team Lead with escalated provider issues
- Assists Team Lead with training staff members
- Assists Manager and Team Lead with quality assurance measures
- Assists in the identification of service level gaps and works with Manager of Provider Relations and Contracts Managers to address recruitment opportunities
- Responding to provider calls on the Provider Services Line queue as well as emails, voicemails and faxes seeking assistance
- Builds collaborative relationships with client health plan counterparts
- Participates in the coordination and processing of Network department mailings
- Responds to provider inquiries and requests for Beacon written materials
- Provider relations experience preferred
10
Provider Relations Rep Resume Examples & Samples
- Must maintain up to date knowledge of TRICARE and ValueOptions policies, processes, and programs. Be familiar with any contract changes that impact behavioral health. Answer providers/facilities questions regarding ValueOptions and TRICARE policies and procedures. Coordinate the processing and follow up of contracts, amendments, rate negotiations, and correspondence for facilities, individual providers and groups
- Act as a liaison between providers, facilities, TRICARE partners and other ValueOptions departments to facilitate communication, resolve inquiries and provide education
- Maintain network adequacy and identify network needs by conducting access surveys to include recruiting additional providers and facilities, as needed, based upon routine monitoring of network adequacy, beneficiary complaints and access to care issues within assigned geographic area. Consult with Manager (or Provider Relations Director, if Manager is not available) to obtain prior approval when exceptional reimbursement is needed
- Responsible for monitoring provider and facility network adequacy, recruitment, education, respond to and document all inquiries. Conduct follow-up activities for behavioral health providers and facilities within your assigned territory. Submit network analysis reports as needed or requested
- Facilitate and conduct all provider/facility education to assigned network providers according to segmentation criteria. Schedule and conduct welcome call to providers no later than 30 days from effective date and provide ongoing education as needed
- Exhibit professional verbal and written communication skills
- Demonstrate flexibility in adapting to new situations and demand of the job
11
Provider Relations Rep Resume Examples & Samples
- Performs research and problem resolution on issues related to provider complaints, claims reported to have been processed incorrectly, coordinating credentialing paperwork, provider communications or verification of information as requested
- Provides assistance in compilation and mailing of provider recruitment mailings, general information and educational materials to network practitioners as required
- Works closely with regional Network Services team to ensure seamless customer service to providers
- Answers practitioner/facility recruitment questions regarding ValueOptions policies and procedures
- Provides follow up with practitioners and facilities for the return of completed credentialing and re-credentialing applications
12
Provider Relations Rep Resume Examples & Samples
- Recruitment and Network Monitoring – Research and identify new providers for recruitment into the ValueOptions provider network
- Research and Problem Resolution – Perform research and problem resolution on issues related to provider complaints, claims reported to have been processed incorrectly, coordinating credentialing paperwork, provider communications or verification of information as requested
- Customer Service – Perform responsibilities and tasks in ways which promote good will, build positive relationships, preserve human dignity and contribute positively to the service commitment of the Company
- Administrative Support – obtain, process, manage and maintain both hard-copy and computer based provider information necessary for development and maintenance activities
- Proficiency in Microsoft Word & Excel
- Knowledge of provider benefits administration/health care setting
- Knowledge of and experience with providers and provider networks
13
Provider Relations Rep Resume Examples & Samples
- Initiates phone calls with customer’s (providers/pharmacies/patients/carriers etc.), and answers incoming communication to customers, confirms receipt of mailing and answers inquires
- Reviews and analyzes documentation and claims data to determine validity and proper action
- Participates in support function activities including documentation, refund support, and/or linking)
- Performs other functions as assigned
- 3+ years’ experience as an examiner/processor with exposure to medical terminology and claim processing experience in Commercial Insurance or Government Programs required
- 3+ years previous experience in a claims customer service environment OR
- 3+ years of answering inbound calls regarding claims processing
- Previous experience as an examiner/processor in an audit recovery area preferred
14
Senior Provider Relations Rep Resume Examples & Samples
- Recruits and negotiates provider contracts with behavioral health providers and practice groups
- Assures compliance with respective provider contracts
- Interprets Health Net’s policies and procedures. Provides interpretation and clarification of benefits, eligibility, and access to care requirements. Escalates recurring or critical issues as appropriate to management
- Assesses provider-training needs. Develops, implements, and conducts appropriate training programs for providers
- Negotiates Single Case Agreements (SCAs) with providers as needed
- Monitors provider database of current data relating to provider information
15
Provider Relations Rep Resume Examples & Samples
- Understands and explains fee-for-service and risk contracts, and provides reporting on provider and/or Service Fund performance
- Maintains provider data integrity including monitoring provider credentialing, location additions, demographic updates, and terminations
- Required Intermediate Microsoft Outlook
- Required Intermediate Microsoft Word
16
Provider Relations Rep Resume Examples & Samples
- Minimum of five years healthcare experience working in a managed care environment and a minimum of two years experience in a Provider Relations position required
- Epic or equivalent Managed Care electronic medical record system and provider portal applications knowledge preferred
- Experience with various healthcare industry regulatory agencies and requirements including but not limited to CMS, NCQA, DMHC, ICE, DHCS, preferred
- Proficiency in Microsoft Office applications including Word, Power Point, Excel, and Outlook is a must
- Experience with Microsoft Access is also preferred
17
Provider Relations Rep Resume Examples & Samples
- Build professional relationships with physicians and medical office staff. Meets with providers as defined by the management team. Ensures providers understand key communications, dashboards, best practices, tools and resources to improve performance
- Manage and support initiatives to achieve measurable improvements in the performance of the network
- Work within an inter-disciplinary team geared towards improving network performance. Review and explain healthcare analytics reports, financial reports, and quality reports with POD physicians. Understand and be able to explain risk contracts
- Attend and participate in Local Leadership Council (LLC) meetings, and follow-up activities. Completes Network Development Report for the LLC. Support leadership with tracking, executing, and monitoring action items. Serves as a liaison between Presence Health Partners leadership, Physicians, and the Local Leadership Council members
- Execute strategies relating to the development or enhancement of provider networks. This includes, but is not limited to defining provider targets and executing contracting efforts
- Facilitate provider issue resolution. This may include utilizing internal Presence Health Partners teams and follow-up with providers to close the loop of issues and concerns. Issue resolution includes, but is not limited to, general education, claims, billing, referrals, etc
- Works with appropriate support staff to coordinate and execute POD Provider and Manager Meetings. Gives presentations when required
- Responsible for utilizing software programs to track site visits, daily activities, tasks for self and teammates (when necessary), in addition to other functions. Produce report as requested by manager. Become proficient in and utilize software. Current systems include Marketware / MD-Staff
18
Provider Relations Rep Resume Examples & Samples
- Recruitment and Network Monitoring – Research and identify new providers for recruitment into the Beacon Health Options provider network. Initiate written and/or telephonic requests to providers for credentialing information. Responsible for the coordination and implementation of activities necessary for the identification, review and selection of mental health, substance abuse treatment, EAP, and disability providers in support of Beacon Health Options network development
- Research and Problem Resolution – Perform research and problem resolution on issues related to provider complaints, claims reported to have been processed incorrectly, coordinating credentialing paperwork, provider communications or verification of information as requested. Create and/or request reports for network management. Review and analyze provider information and status through database queries. Regularly review all network management reports (i.e. denial reports, disenrollment grids, pend reports, credentialing status reports) and research information regarding providers and the area(s) served. Research files and databases to address provider questions. Resolve customer/member/provider claims issues through investigation and problem solving. Follow-up on inquiries as needed, referring problems to other appropriate Beacon Health Options personnel as identified. Research provider rate increase requests
- Customer Service – Perform responsibilities and tasks in ways which promote good will, build positive relationships, preserve human dignity and contribute positively to the service commitment of the Company. Service calls in a professional and courteous manner. Work closely with Network Services and Network Operations teams to ensure seamless customer service to providers. Interface with CSRs, Care Managers, Claims staff, account management and other service center staff to give information about provider contract/credentialing status to facilitate claims payment and referrals. Interface with external and internal customers to ensure optimal efficiency of service. Address concerns of dissatisfied and/or angry customers and providers in a diplomatic manner. Respond to customer inquiries professionally and efficiently. Assist in day to day department activities including phone coverage and file maintenance
- Administrative Support –Obtain, process, manage and maintain both hard-copy and computer based provider information necessary for network development and maintenance activities. Participate in the maintenance for files within a national database of potential and existing network providers. Attend all staff meetings, team conferences and in-services as directed. Maintain daily logs for future reference and analysis as well as document inquiries and complaints appropriately in ServiceConnect and other applicable databases. Enter data accurately and timely into systems. Perform routine clerical functions including filing, copying, fax, typing and record retrieval
- Knowledge of and experience in provider benefits administration/health care setting
19
Senior Provider Relations Rep Resume Examples & Samples
- Customer Service experience required; provider relations experience required
- Strong understanding of managed care and health care operations. Behavioral health experience preferred
- Must be able to work collaboratively with internal staff and external providers
20
Provider Relations Rep Resume Examples & Samples
- Provide ongoing education and assistance to providers and facilities
- Coordinate activities with internal departments and external partners to optimize customer service to network providers, non-network providers, facilities and internal customers
- Monitor provider and facility adequacy, recruitment, education, respond to and document all inquiries. Conduct follow-up activities for behavioral health providers and facilities
- Provide administrative support to the Provider Relations team. This would include but not limited to, following up on all return mail, follow-up on provider change request, conduct demographic outreaches, assist with researching and locating providers for recruitment into the network, as well as, sending providers educational materials and yearly fee schedule
- Maintain up to date knowledge of the contract and company policies, processes, and programs. Be familiar with any contract changes that impact behavioral health. Answer provider/facilities questions regarding contract policies and procedures
- Must possess the ability to work as a team player on a team of personnel with different skill sets
- Proficient in MS Office Suite
21
Provider Relations Rep Onondaga County Resume Examples & Samples
- Proficiency in Microsoft Office: Excel, Word, Access; Outlook; Internet
- Knowledge of various quality programs, including measures associated with QARR and HEDIS
- BA/BS - Bachelors Degree or equivalent required
22
Provider Relations Rep Jefferson & Lewis Counties Resume Examples & Samples
- Customer Service: Skilled to communicate with all levels of management, internal and external customers
- Three to five years experience working in a managed care environment serving in Provider Relations, Contract Management, or equivalent role
- Valid drivers license and vehicle required
23
Provider Relations Rep Albany North Country Resume Examples & Samples
- Knowledge of various provider payment methodologies and claims processing required
- Business Analysis Knowledge: Skilled to work in a fast paced environment. Must have strong analytical and problem solving skills
- REQUIREDto reside in one of the counties listed. - Counties include; Essex, Franklin, St. Lawrence, Hamilton and Clinton
24
Provider Relations Rep Mid-hudson Resume Examples & Samples
- Knowledge of various provider payment methodologies and claims processing
- Effective Business Communication: Skilled in communicating with technical and business constituencies in writing effective business specifications and requirements
- Should reside in or near Mid-Hudson area
- Five to eight years related experience required
25
Provider Relations Rep-ne Resume Examples & Samples
- Fosters a close working relationship with assigned physician offices including communicating with provider office regarding member service issues. Researches concerns/issues for provider offices and provides accurate and timely answers. Assists provider offices in ensuring compliance with SJHAP, SJHMG, and Health Plans. (30%)
- In-services new and established physician offices on policies and procedures of SJHAP, SJHMG, Network Support Services (NSS) and health plans. Provides on-going education to assigned offices regarding such policies and procedures. Documents all site visits and provider issues for trending and reporting. (25%)
- Educates physician offices on Point of Care Tools i.e. Ascender and Physician Connect. (10%)
- Conducts physician office staff meetings and other network meetings as needed. (10%)
- Acts as a liaison with various SJHAP/SJHMG Departments and physician offices and health plan to resolve provider issues. (10%)
- Informs health plans on addition, deletion, and panel closure of participating providers. Maintains current Provider Directory. (10%)
- Assists with business development as assigned. (5%)
- Verifies Health Plan Provider Directory
- Age-specific patient needs that employee is required to understand and meet
- Additional requirements
- A minimum of 1 year experience working with physicians in a managed care/IPA, Medical group, health plan or MSO environment, prior Provider Relations or Customer Service experience
- Working knowledge of managed care principles and methodologies
- Strong interpersonal and organizational skills to achieve desired goals and to interact effectively with management and non-management personnel and physician groups
- Attention to detail and follow up skills required
- Must be able to maintain a positive attitude with changing conditions
- Seek out available resources to resolve problems
- Demonstrate dependability
- Must be able to work under minimal supervision
- Must be able to work in a fast-paced department and handle multiple tasks, work with interruptions, and deal effectively with confidential information
26
Parkland Provider Relations Rep Resume Examples & Samples
- PRIOR Medicaid calls and claims processing a plus
- Working knowledge of Business Review/Credentialing processes, EPDB,EPC,CARDS a plus
- Exceptional communication skills; verbal, written and presentation
- Ability to multitask, prioritize and effectively adapt to a fast paced changing environment
27
Provider Relations Rep-bilingual Bengali & Urdu Resume Examples & Samples
- Completes new provider orientation for all applicable product lines
- Achieves frequency goals to establish consistent and strong relationship with provider offices
- Required A Bachelor's Degree in a related field OR equivalent work experience
- Required 1+ year of experience in a Provider Relations, Account Management, Customer Service or relevant position with demonstrated ability to perform the duties of the position
- Intermediate Demonstrated analytical skills
28
Provider Relations Rep-miami Gardens Resume Examples & Samples
- Partners with local and national ancillary for appropriate vendor management and coordinates the transition of the delegated providers following a network termination
- Intermediate Demonstrated time management and priority setting skills
- Intermediate Ability to represent the company with external constituents
29
Provider Relations Rep Resume Examples & Samples
- Develop single case agreements with out of network providers that serve Passport members in accordance with clinical guidelines and state regulations
- Document execution of specific controls and processes in accordance with SOC, Model Audit Rule and other audit requirements
- Coordinate with providers, Plan representatives and clinical teams to execute a completed single case agreement that reflects medically necessary services in the most appropriate level of care possible
- Provide administrative support for Plan team in relation to provider related concerns (provider outreach, claims review, status reports)
- Provide information to Passport Health Plan to assist in the processing of claims, including reports, claims denial reasons and claims impact analyses
- Demonstrate ability to meet strict deadlines and established cycle times through effective prioritization and routine follow up strategies
- Minimum 2-3 years of customer service experience required
- Behavioral health experience preferred
- Basic Microsoft Office knowledge
- Intermediate Excel knowledge and skills
- Strong understanding of PowerPoint and Microsoft Project
- Group presentation and public speaking skills
- Collaboration and team-oriented work philosophy
