Provider Relations Rep Resume Sample
Addie Maggio
551 Armstrong Isle,
Houston,
TX
+1 (555) 685 4758
Work Experience
Senior Provider Relations Rep
03/2018
-
PRESENT
Houston, TX
- 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
- Initiates phone calls with customer’s (providers/pharmacies/patients/carriers etc.), and answers incoming communication to customers, confirms receipt of mailing and answers inquires
- Responsible for maintaining strong working relationships with the existing provider network
- Assists providers with policy and procedure interpretation
- Maintains accurate and current databases relating to provider facilities and physician information
- 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
Provider Relations Rep
06/2013
-
09/2017
Boston, MA
- 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
- Conducts provider office site visits as necessary to ensure site meets contract guidelines
- Ensures provider database and documentation is up-to-date, accurate, and complete; ensures new physician contracts are entered promptly and accurately
- Assists with the development and implementation of provider training programs
- Performs special projects as assigned. LI-Wellcare
- 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, etc
- Previous experience in a claims customer service environment OR2+ years of answering inbound calls regarding claims processing
- Healthcare experience (claims, enrollment)
- Make outgoing calls to customers (providers/pharmacies/patients/carriers, etc.) to confirm receipt of mailings and request action
Provider Relations Rep-bilingual Bengali & Urdu
06/2009
-
12/2012
San Francisco, CA
- Assist with Meaningful Use Attestation Submission Project, per guidelines outlined by Medicare and Medicaid
- Assure that all provider orientations, site visits, access and availability studies are completed within designated timeframes; assure that all providers are visited within established timeframes
- Facilitate retrieval of Fidelis Care New York’s member healthcare records to ensure achievement of optimum QARR scores
- Conduct Access and Availability studies as needed; conduct Delegated Credentialing audits and on-site provider office assessments required for credentialing
- Complete credentialing and re-credentialing audits for delegated providers
- Investigate and resolve member complaints regarding providers to maintain member and provider satisfaction; clarify the provider's problem; determine the cause of the problem; select and explain the best solution to solve the problem and expedite correction or adjustment; follow up to ensure resolution
- Assist Contract Management in identification of network deficiencies and make recommendations on how to address them
- Establish and foster strong, positive relationships with key providers by coordinating, facilitating and leading partnership meetings and identifying onsite enrollment opportunities for Marketing
Education
DeVry University's Keller Graduate School of Management
2003 - 2008
Bachelor's Degree in Business Administration
Professional Skills
- Proficient in Microsoft Office skills (Excel, Word, Access, etc.)
- Related professional experience in a health plan, medical group or IPA setting working with physician networks
- Experience in managed care with contracting and credentialing Providers
- Experience in health care field
- Medical terminology, medical billing, medical offices procedures
- Enjoys working in both individual and team settings
- Problem solver – enjoys problem solving
How to write Provider Relations Rep Resume
Provider Relations Rep role is responsible for reporting, auditing, database, training, research, health, coding, marketing, contracts, benefits.
To write great resume for provider relations rep job, your resume must include:
- Your contact information
- Work experience
- Education
- Skill listing
Contact Information For Provider Relations Rep Resume
The section contact information is important in your provider relations rep resume. The recruiter has to be able to contact you ASAP if they like to offer you the job. This is why you need to provide your:
- First and last name
- Telephone number
Work Experience in Your Provider Relations Rep Resume
The section work experience is an essential part of your provider relations rep resume. It’s the one thing the recruiter really cares about and pays the most attention to.
This section, however, is not just a list of your previous provider relations rep responsibilities. It's meant to present you as a wholesome candidate by showcasing your relevant accomplishments and should be tailored specifically to the particular provider relations rep position you're applying to.
The work experience section should be the detailed summary of your latest 3 or 4 positions.
Representative Provider Relations Rep resume experience can include:
- Proactively identify provider needs and advise management so that action can be taken to address the needs before they are problematic for the provider. Educate providers on the Plan’s provider incentive programs
- Conducts ongoing needs assessment to provide continuous quality improvement, including focus groups, surveys and audits of existing procedures
- Creates, maintains and audits provider database, including contract relationships, specialty data and demographic information
- Acts as provider contract administrator, including initial review, interpretation and compliance
- Communicates plan information alerts, including policy changes, to the provider panel
- Coordinates and participates in special projects requiring a multi-disciplinary approach
Education on a Provider Relations Rep Resume
Make sure to make education a priority on your provider relations rep resume. If you’ve been working for a few years and have a few solid positions to show, put your education after your provider relations rep experience. For example, if you have a Ph.D in Neuroscience and a Master's in the same sphere, just list your Ph.D. Besides the doctorate, Master’s degrees go next, followed by Bachelor’s and finally, Associate’s degree.
Additional details to include:
- School you graduated from
- Major/ minor
- Year of graduation
- Location of school
These are the four additional pieces of information you should mention when listing your education on your resume.
Professional Skills in Provider Relations Rep Resume
When listing skills on your provider relations rep resume, remember always to be honest about your level of ability. Include the Skills section after experience.
Present the most important skills in your resume, there's a list of typical provider relations rep skills:
- Experience working with people of varying levels within the organization
- Significant amount of time spent working in a loud office environment with frequent interruptions/distractions
- Knowledge of managed care principles and methodologies
- Self-starter, resourceful and able to execute projects in a fluid and fast paced environment
- Extensive Knowledge of the Meaningful Use Submission Process for Medicare and Medicaid
- Bilingual - Completely bilingual in English and Spanish, written and verbal
List of Typical Skills For a Provider Relations Rep Resume
1
Skills For Provider Relations Rep-ne Resume
- T apply common sense understanding to carry out instructions furnished in written, oral, or diagram form; ability to deal with problems involving several concrete variables in standardized situations
- Experience as an examiner/processor with exposure to medical terminology and claim processing experience in Commercial Insurance or Government Programs required
- 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
- Experience in business segment environment servicing providers with exposure to benefits and/or contract interpretation
- Comprehensive knowledge of all Microsoft Office applications, including Access, Excel, and Word. Proficiency in EzCap 6.0, Ascender and Crystal Reports. Previous experience working in a reporting / analytics team. Proven ability to manage large databases. Knowledge of and experience
- Set goals and assess results in accordance with the highest standards; work with sensitivity and respect; advance care through development of new ideas and technology; promote teamwork to achieve
2
Skills For Senior Provider Relations Rep Resume
- Coordinates and participates in provider credentialing process
- Trains staff in claims submission and referral/authorization policies and procedures
- Acts as a resource to interpret benefit plans for providers
- Stays abreast of regulatory, legal and legislative issues and requirements and communicates changes internally as well as to appropriate providers
- Performs needs analyses, researches and writes health plan policies and procedures
- Acts as the expert consultant to senior management
- Determines and provides needed support as required
- Maintains and protects the confidentiality of applicable health plan activities
3
Skills For Provider Relations Rep-bilingual Bengali & Urdu Resume
- Trains staff in claims submission and referral/authorization policies and procedures. Conducts ongoing needs assessment to provide continuous quality improvement, including focus groups, surveys and audits of existing procedures
- Acts as provider contract administrator, including initial review, interpretation and compliance. Acts as a resource to interpret benefit plans for providers
- Communicates plan information alerts, including policy changes, to the provider panel. Stays abreast of regulatory, legal and legislative issues and requirements and communicates changes internally as well as to appropriate providers
- Coordinates and participates in special projects requiring a multi-disciplinary approach. Determines and provides needed support as required
- Performs needs analyses, researches and writes health plan policies and procedures. Acts as the expert consultant to senior management
- Completes new provider onboarding which includes: processing executed agreement; provider office orientation for all applicable product lines and ongoing provider services,
- Conducts site visits to service providers on policies and initiatives, resolve issues, educate staff/providers on policies, collect credentialing information and others
4
Skills For Parkland Provider Relations Rep Resume
- Utilizes standardized processes, tools, researching and resolves routine or complex issues relating to provider services which include eligibility, provider availability and claim related issues and others
- Understands and explains fee-for-service and risk contracts, as needed during onboarding
- Works on special network and contracting projects as needed
- Participate in the Network Management activities which include: outreach to Providers, negotiating contacts, updating he master Provider file, handling complains, and updating provider portal and materials as needed
- Assist with physician recruitment 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
- Achieves strong relationship with provider officers, TPA, Professional Staff Office and others
- Providing articles and information for publication on the Clinic’s website for physicians and managers
5
Skills For Provider Relations Rep Mid-hudson Resume
- Help to secure completed contracts and credentialing materials from key providers who have been invited to join the network
- Investigating and resolving claims issues for existing members; assist enrollment with checking participation status of existing members who have claims paying out-of-network; recognizing trends (claims, participation status, etc.) affecting majority of the Clinic practices
- Provide monthly or as-needed communications on each health plan’s changes (e.g., bundling, pre-cert requirements, issues affecting most Clinic member practices, etc.)
- Creating, maintaining and distributing a Clinic “office manual,” providing information on who to call for issues that arise, the new Clinic member process, etc
- Develops and hosts quarterly, interactive “Managed Care Breakfast” meetings for practice managers and their staff
- Act as a resource for providers about Beacon, its contracts, policies and procedures. Provide accurate and timely responses to provider inquiries, issues and requests
- Regularly interact and establish solid working relationships with Customer Service, Clinical, Claims, Network Operations, IT and Contracting in resolving provider and other operational issues
6
Skills For Provider Relations Rep-miami Gardens Resume
- Engage providers in Beacon’s quality improvement activities
- Strategize with members of the management team to ensure access and availability of providers meets current standards
- Be the liaison between providers and other Beacon departments
- Participate in development and maintenance of plans to meet performance guarantees
- QNXT knowledge (ADVANCED)
- Providing initial contact and follow up with new Clinic members and their staff regarding the managed care payor network participation loading process; the Clinic’s payor fee schedules; what to expect regarding claims processing when joining the Clinic; and work closely with the Clinic’s Quality Specialists for practice-specific issues
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