Provider Relations Representative supports, develops and maintains service relationships with all participants (physicians, providers and administrators) of a provider network. Responds to electronic and direct inquiries from clients about policies, rates, changes, referrals, eligibility, credentialing, etc. Typically requires a bachelor's degree. Being a Provider Relations Representative typically reports to a supervisor or manager. The Provider Relations Representative works on projects/matters of limited complexity in a support role. Work is closely managed. To be a Provider Relations Representative typically requires 0-2 years of related experience. (Copyright 2024 Salary.com)
POSITION SUMMARY/RESPONSIBILITIES
Provider Relations Representative works as the primary liaison between Community First Health Plans and network participants (physicians, providers, and administrators) of the health plan provider network. This position will build and nurture positive relationships with health plan network participants by providing the on boarding orientation, and delivering guidance and high-quality service through regular engagement by phone and through scheduled in-person visits to targeted provider offices. This position will also coordinate with: Compliance & Quality staff on the re-credentialing process; with Provider Contracting staff for contracting issues or concerns; and will periodically assist the Claims staff with auditing and troubleshooting of provider data to ensure proper claims adjudication. The Provider Relations Representative knows and abides by all organizational and departmental policies, sets personal standards, and strives for high quality work in completing assignments, performs job duties in a timely manner, and represents the organization in a positive manner.
EDUCATION/EXPERIENCE
A minimum of five years of related experience in the health care or managed care field of customer service-related work is required. Bachelor’s degree in business, health care, communications, or other related area is preferred. Recent experience as a provider relations representative, member service representative, or relevant claim experience is highly preferred.
LICENSURE
Valid Texas driver’s license as well as a reliable vehicle is required.