Provider Relations Representative Resume Sample
Julian Beahan
5013 Johns Overpass,
New York,
NY
+1 (555) 872 0018
Work Experience
Senior Provider Relations Representative
09/2017
-
PRESENT
Philadelphia, PA
- 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
- 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
- Informs health care providers of the status of their COHE applications and contacts them if additional information is required. Proactively processes new health care providers and records changes in personnel or contact information at participating health care organizations
- Tracks and follows-up on requests for continuing education data
- Maintains provider enrollment, education status and turnover logs to ensure there is accurate L&I data
- Develop and maintain trusting, personal relationships with SWHP providers and their office staff via office visits, telephone calls, and correspondence
- Meet weekly provider contact goals
Provider Relations Representative
09/2013
-
05/2017
Houston, TX
- Assist the Credentialing Team by performing site visits/surveys as needed
- Identify gaps in the network and works with the Network Development Team to find providers to contract with to fill the gaps
- Serve as the liaison for SWHP providers and delivers timely and accurate responses to all provider concerns and issues
- Work with internal departments to ensure providers have a complete resolution
- Work with the Quality Improvement Team on various HEDIS initiatives with SWHP providers
- Creates and manages training curriculum related to subject matter including provider relations staff trainings, provider orientations and ongoing provider support
- Plan and facilitate trainings using various technology solutions, including new applications and procedures
- Lead classroom-style training sessions remotely, in-person and via WebEx/video conference
Affiliate Provider Relations Representative
06/2010
-
05/2013
Detroit, MI
- Prepare reports and analyze data as directed by the Manager of Provider Relations or other members of the management team
- Report to each scheduled shift and commence work and perform essential job function at the start of each schedule shift
- Displays a positive, constructive, and helpful demeanor that is conducive to a safe and respectful work environment
- 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
- Proactively strategizes for membership growth and retention, through advanced communication to providers, as well as follow-up to gauge the response to that growth
- Validates completed provider agreements and returns to providers for further review and modifications
- Ensures that all pharmacy, medical supply & equipment and dental providers’ required agreement information is entered into the Express Scripts Canada System in a timely manner
- Ensures that all pharmacy, medical supply & equipment and dental providers’ modifications and terminations are updated in a timely manner
- Handles provider, association and software vendor inquiries in a professional and knowledgeable manner
Education
Buena Vista University - Mason City Campus
2005 - 2010
Bachelor's Degree in Health Care Administration
Professional Skills
- Experience in a role requiring strong oral communication skills including telephone etiquette
- Excellent problem solving skills, good follow-up abilities and willingness to be flexible and adaptable to changing priorities
- Verbal and written communication skills; organizational and planning skills
- Excellent communication, training and speaking skillsHighly organized but willing to adjust direction when necessary
- Strong organizational, problem solving and decision making skills
- Intermediate time management and priority setting skills
- Strong verbal and written communication, interpersonal, problem resolution and critical thinking skills
How to write Provider Relations Representative Resume
Provider Relations Representative role is responsible for research, database, basic, organizational, word, crm, etiquette, salesforce, negotiation, computer.
To write great resume for provider relations representative job, your resume must include:
- Your contact information
- Work experience
- Education
- Skill listing
Contact Information For Provider Relations Representative Resume
The section contact information is important in your provider relations representative 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 Representative Resume
The section work experience is an essential part of your provider relations representative 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 representative 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 representative position you're applying to.
The work experience section should be the detailed summary of your latest 3 or 4 positions.
Representative Provider Relations Representative resume experience can include:
- Strong interpersonal skills with ability to work independently with minimal supervision; and as a team player willing to take direction
- Excellent follow-through skills, self-motivated and detail-oriented
- Outstanding customer service and negotiation skills
- Solid understanding of health insurance, customer messaging/design and ability to manage multiple priorities to successful completion required
- Computer literate, possessing intermediate skills in MS Office (Word, Excel, Outlook), and Adobe Reader and Writer
- Prior experience in a health care setting highly desirable
Education on a Provider Relations Representative Resume
Make sure to make education a priority on your provider relations representative 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 representative 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 Representative Resume
When listing skills on your provider relations representative 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 representative skills:
- Strong organizational skills to manage multiple projects, issues, and priorities effectively and simultaneously, with attention to detail
- Communication (written, verbal and listening), analytical, negotiation, business acumen, organization, strategic, multitasking and prioritization skills
- Consultant is skilled at determining when issues are not being effectively resolved and appropriately elevates issues to management as needed
- Good communication (written and oral), interpersonal, problem resolution and critical thinking skills
- Strong technical, analytical, and trouble-shooting skills
- Good PC Skills. Typing helpful
List of Typical Experience For a Provider Relations Representative Resume
1
Experience For Senior Provider Relations Representative Resume
- Experience utilizing research and analytical skills
- Relevant Work Experience: 2-3 years Customer Service experience with 2-3 years Claims experience required
- Strong customer service focus - understanding the Express Way Values
- Experience using McKesson Program Manager application
- Experience working in a managed care environment
- Professional experience in a managed care setting
- Successfully manage multiple competing priorities
- Experience working in a complex organizational environment is required
2
Experience For Provider Relations Representative, Senior Resume
- Providing articles and information for publication on the Clinic’s website for physicians and managers
- Understanding of interdependencies between internal company divisions and constituent impacts
- Conducts and manages on-going review of contract installations; partners with quality management in identifying, analyzing and reporting on trends
- Significant competencies in resolving disputes, identifying resolutions
- Conducts educational workshops for participating providers and staff to enhance their understanding of Government Enrollment policies and procedures
- Knowledge of healthcare/pharmacy, medical supplies & equipment or dental benefit administration and claims processing is an advantage
- Coverage area – Birmingham and surrounding metro area
3
Experience For Affiliates Provider Relations Representative Resume
- Assist with 837 Reporting Activities as it relates to provider submissions
- Assist with Coordinating Single Case Agreements (SCA) for the Engagement Center
- Performs level 3 testing on NetworkConnect enhancements
- Coordinates updating promise ID numbers in NetworkConnect
- Assist with the ongoing review of the promise ids of the in network providers
- Assist/Research with answering questions from both internal and external customers as it relates to contracts
- Responsible for assisting in the implementation of monthly action plans, reviews, and verification
- Analyze and monitor provider cost reports on an ongoing basis in order to educate and improve providers’ cost and quality performance
- Provide backup to team for incoming queue calls
4
Experience For Affiliate Provider Relations Representative Resume
- Understand cost implications in each market when assigning specialty providers and one-time placements
- Provide issue resolution and complex trouble shooting for providers
- Monitors agreements containing specific time-limited provisions to ensure adherence to expiration dates
- Analyzes trends and develop reports regarding utilization and quality management for PCP offices
- Define project tasks and resource requirements utilizing A3 methodology
- Knowledge regarding managed care and various provider reimbursement methods. hospital/physician office practice operations and management
- Comfortable working in a fast-paced environment
- Proficiency with Microsoft programs including Excel (sort & filter data) and Word (create & edit documents)
5
Experience For Provider Relations Representative, Dental Resume
- Proficiency with Microsoft programs including Excel (capable of basic Excel manipulation) and Familiar with Word Perfect (proficient)
- Proficiency with Microsoft programs including Excel (capable of basic Excel manipulation)
- Use PC-based word processing and spreadsheet applications, preferably the Microsoft Office suite of products
- Bilingual and Asset (French & English)
- Analyze, problem-solve and mediate difficult situations
- Communicates with State’s Workers’ Compensation agencies
6
Experience For Healthcare Vision Senior Provider Relations Representative Resume
- Maintain and update any provider databases (as deemed appropriate)
- Perform site visits to waiver and other providers, as appropriate
- Participates, organizes and manages workbooks for provider operational meetings
- Monitors corrective action plans, and manages the implementation of plan(s) collaboratively within HPHC
- Demonstrates a thorough understanding of network providers’ contractual and reimbursement arrangements. Is conversant with contractual terms of all provider types (i.e., physician, hospital and ancillary) in the HPHC provider network
- Communicates to internal constituents regarding critical issues that impact the providers’ overall performance and satisfaction. Consultant is skilled at determining when issues are not being effectively resolved and appropriately elevates issues to management as needed
- Work with internal departments to identity the root cause analysis and resolution of problems and issues provider is having
7
Experience For Provider Relations Representative MSO Resume
- Serve as a liaison between us and the provider community
- Identify, discuss, and resolve various issues for providers
- Respond to provider requests for research and resolution to various complaints
- Disseminate/communicate information to internal colleagues communicate significant information to appropriate department representative and/or other departments
- Support any department administrative requirements including educational documents, organizing webinars, and supporting other reporting needs
- Educate provider offices concerning provider enrollment and credentialing process
8
Experience For Healthcare Provider Relations Representative Resume
- Identifies and resolves provider issues by researching causes and working with Beacon’s clinical, operations and IT teams
- Interact with Claims Dept. regarding payment schedules and rates of reimbursement
- Ensure providers are following proper referral procedures, information/authorization, covered service guidelines, and submission of claims
- Perform in-service/education to providers as needed
- Maintain internal vendor lists/Provider Network Lists for internal departments
- Acts as primary liaison with the Healthcare provider network
- Research and resolve provider escalations issues and manage work items through department queues, working closely with other departments as well as communicating with providers and other office staff to facilitate and resolve carious escalation issues
9
Experience For Hospital Outreach Phycisian & Provider Relations Representative Resume
- Outreach to providers offices via phone and email to support revalidation initiatives, to obtain contact information, clarify provider structure, and identify affiliated providers
- Partners with other internal departments, including but not limited to Health Services, Finance, Claims, and Coding in order to develop solutions for strategic business needs
- Engaging providers in Beacon’s quality improvement activities
- 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
- 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
- Completes the Temporary Promise Enrollment Application as needed for Out of Network providers
10
Experience For Healthcare Provider Relations Representative Maine Resume
- Works with Claims and Customer Service to resolve claims issues for single case agreements
- Supports quality initiatives for the Network Operations Department within the engagement center
- Assist in the completion of contract amendments
- Oversees file and database research to address provider questions
- Assists with the completion of Promise applications for master level practitioners
List of Typical Skills For a Provider Relations Representative Resume
1
Skills For Senior Provider Relations Representative Resume
- Excellent organization, presentation, and written and verbal communication skills
- Intermediate computer skills, including electronic mail, routine database activity, word processing, spreadsheet,
- Basic computer skills required, including Wor, Excel and Outlook
- Two years' experience in Billing, Provider Relations, Insurance Verification or related work experience
- Experience in a position that demonstrates leadership abilities and sound decision-making
2
Skills For Provider Relations Representative, Senior Resume
- Proficient in Microsoft Office skills (Excel, Word, Access,etc.)
- Medical Office experience or Sales experience
- Intermediate interpersonal/verbal communication skills
- Intermediate customer service skills
- Self-starter who takes imitative and adapts well to change. Ability to work effectively with limited oversight
- Effectively communicate the MultiPlan Value Proposition
- Experience interacting and communicating with providers in a healthcare setting required
3
Skills For Affiliates Provider Relations Representative Resume
- Strong understanding of RxClaim processing system and / or other PBM adjudication platforms
- Experience and ability in developing provider or facility networks, knowledge of claims processing, managed care plan benefits and utilization management
- Develop and maintain effective working relationship with member services department, medical management department and sales and marketing departments
- Experience in a professional or corporate setting
- Previous experience in a role requiring outbound calls
- Experience working in a health care space with managed care systems
4
Skills For Affiliate Provider Relations Representative Resume
- Experience working in a health care environment
- Demonstrates a thorough understanding of network providers’ contractual and reimbursement arrangements
- Provider Relations experience
- Experience within a Managed Care Company
- Valid California Driver’s License for travel between St. Joseph Heritage Healthcare locations
- Own transportation for office and site visits (10% - 50% travel required). Valid driver’s license required
- Experience in customer service, public relations, education or related field
- Good knowledge with Microsoft Excel and other Microsoft Products (Powerpoint, Word, Outlook)
5
Skills For Provider Relations Representative, Dental Resume
- Demonstrated knowledge of contracts, Medicare fee schedules, financial terms, and metrics
- One or more years of experience in a health plan, MSO (medical services organization) and/or IPA (independent practice association)
- Internal or external client presentation experience
- Experience with issue resolution
- Related experience in the healthcare industry, preferably HMO
- PBM (Prescription Benefit Management) experience
- Customer service or account management experience
6
Skills For Healthcare Vision Senior Provider Relations Representative Resume
- Experience with Microsoft SharePoint (navigate through the application)
- 2 years' related experience in the healthcare industry, preferably HMO
- Access and power point experience
- Experience in claims, customer service or provider support role
- Experience in provider claims, customer service or in a healthcare support role
- Contract negotiation experience at a health plan or medical group
- Experience in provider relations
7
Skills For Provider Relations Representative MSO Resume
- Experience with business segment specific policy, benefits, plan design and language
- Valid driver's license and vehicle required
- Related work experience in healthcare environment
- Valid driver's license and a vehicle required
- Develops strong interpersonal relationships with assigned providers important to Aetna's success in Oklahoma
- Knowledge and experience in provider reimbursement methods
- Build strong provider relationships
8
Skills For Healthcare Provider Relations Representative Resume
- Make a good judgment conclusions based on data available with minimal supervision
- Working knowledge of Medicaid, Medicaid manage care, and/or commercial health plan managed care
- Working knowledge of business segment specific codes, products, and terminology
- Working knowledge of Medicaid and/or government managed care products and terminology
- Intermediate level of proficiency with Microsoft Word and Microsoft Excel (Word - creating and editing docs / Excel - reviewing and analyzing data)
- Basic to Intermediate proficiency in Microsoft Office products and learning reporting applications
9
Skills For Hospital Outreach Phycisian & Provider Relations Representative Resume
- Knowledge and understanding of provider finance components including budget, charge structure, reimbursement formulas and healthcare finance
- Recruit participating and non-participating providers to higher level of participation for all applicable market LOBs
- Knowledge of medical terminology, medical billing, and medical office procedures
- Problem solver – enjoys problem-solving
- Maintains a COHE list of participating employers and labor unions
- Creates and/or manages cooperative working relationships with providers and/or through personal visits, correspondence and telephone contact
- Thorough understanding of provider network management and internal operations
- Coverage area - surrounding counties
- Proficiency with MS programs including Excel (create spreadsheets, sort / filter / manipulate data)
10
Skills For Healthcare Provider Relations Representative Maine Resume
- Proficiency with MS programs including Excel (create spreadsheets, sort/filter/manipulate data)
- Work in a traditional professional office setting or remote equivalent
- Proficiency with MS programs including Excel and Word
- Health care marketing/provider
- Proficiency building customer relationships
List of Typical Responsibilities For a Provider Relations Representative Resume
1
Responsibilities For Senior Provider Relations Representative Resume
- Prioritize and manage multiple projects and issues effectively and simultaneously
- Strong attention to detail, research and follow up skills
- Basic admin skills of SalesForce or other CRM tool
- Basic report skills SalesForce or other CRM tool
- Valid driver’s license, reliable transportation, and insurance are required, mileage reimbursed. Requires 50% - 75% local travel in coverage area
2
Responsibilities For Provider Relations Representative, Senior Resume
- Experience in the business system analysis industry
- Valid PA drivers license and reliable car
- Support the retention of providers by participating in meetings, conducting research, and supporting provider credentialing
- Assist management in tracking, trending and reporting on provider recruitment and retention
- Conduct on-site visits. Tasks include orientation, training, and working with providers and staff to problem solve day-to-day issues and identify barriers
- Assist and / or lead strategic projects specifically focused on mitigating risk and proactively protecting the company’s financial interests
3
Responsibilities For Affiliates Provider Relations Representative Resume
- Recruitment of providers identifying specific providers and small provider groups in the states/counties of their area assigned by the Network Administrator
- Perform site visits to conduct outreach, education, training and orientation sessions for providers and key administrative staff
- Resolution of data discrepancies in network connect
- Resolve returned mail issues
- Responsible for provider network development, including physician contracting, rate negotiations, network relationships, network communication, physician recruitment, and network partners
- Researches and resolves provider issues
- Occasional night meetings required
- Proficiency with Microsoft Office including Microsoft Word (creating and editing documents), Microsoft Excel (creating and modifying spreadsheets), Microsoft PowerPoint (creating and editing presentations), and Microsoft Outlook (managing email and calendar)
4
Responsibilities For Affiliate Provider Relations Representative Resume
- Strong interpersonal, organizational and critical thinking skills with the ability to perform under pressure and within rigid time constraints without the loss of efficiency, quality and professionalism
- Two years of experience working in a complex organizational environment
- Demonstrated ability to analyze situations and data to identify issues, determine points of relevance, and assess proper courses of action
- Two years of experience in healthcare or managed care environment
- Develop strong interpersonal relationships with providers so there is an enhanced partnership with providers
5
Responsibilities For Provider Relations Representative, Dental Resume
- Manage local territory through utilizing internal job aids and resources
- Provide on demand education and policy/procedural information to provider community as well as internal/external stakeholders
- Follow up on issues identified by providers and their offices
- Work with Business Development Managers to identify areas to recruit providers
- Utilize software systems and databases to provide reports on activities to network administrators
6
Responsibilities For Healthcare Vision Senior Provider Relations Representative Resume
- In conjunction with regional manager develop implementation plans for assigned areas of responsibility
- Assure that all responsibilities are performed consistent with the deliberate plans of the organization
- Represent the organization well at all times; support its mission, goals and objectives; participate as a "team player", constantly supporting other managers; set an example of high personal and professional conduct for employees and others. Maintain personal professional development
- Position involves excessive traveling (75%) to provider offices. Assist in the development and maintain presentation materials for provider forums and meet one on one with providers, hospitals, skilled nursing facilities, etc
- Provider Relations Representative responsibilities include conducting regular provider visits to educate providers and office staff on topics including, but not limited to: health plan operations/policies and procedures, preventative and quality outcome metrics & risk adjustment
- The Provider Relations Representative is responsible for understanding, developing, tracking, monitoring and reporting on key program performance metrics, such as utilization, coding, STARs and quality performance
- The Provider Relations Representative prepares for and participates in meetings with providers, provider staff, and/or physician leadership, and plans, creates and delivers presentations
- Assist in end-to-end provider claims process and help enhance call quality
- Answer questions about the health plan and operational processes
7
Responsibilities For Provider Relations Representative MSO Resume
- Provide direction in use of physician portal and offer input for future services enhancements
- Introduce and familiarize providers on all aspects of the provider manual related to services, benefits and provider requirements; care coordination protocols; claims filing; and health, safety, and welfare education
- Serve as internal liaison with operational departments regarding provider service projects
- Monitor and trend provider issues documented through workflow, calls, emails, and other avenues
- Respond to Network issues, as appropriate
- Assures compliance with respective contracts
- Research, analyze and resolve claim, benefit, issues and authorization inquiries within delegated authority
8
Responsibilities For Healthcare Provider Relations Representative Resume
- Provide interpretation and clarification of benefits, eligibility, and access to care requirements. Escalate recurring or critical issues as appropriate to management
- Assess provider-training needs. Develop, implement, and conduct appropriate training programs and/or orientations for assigned provider staff
- Monitor provider database of current data relating to provider and physician information
- Ensure provider directories are accurate
- Investigate compliance issues, identify root cause, train provider office staff on correct procedures, and provide written report of findings and recommendations
9
Responsibilities For Hospital Outreach Phycisian & Provider Relations Representative Resume
- Meet on a regular basis in person or by telephone with assigned key provider groups to cultivate and strengthen relationships
- Document office visits and provider issues on shared drive log
- The Provider Relations Representative (Network Operations Senior Analyst) develops and maintains positive relationships with physicians, providers, and practice managers within the provider network, including oversight and managing performance in various incentives based and/or value based programs
- People are our best asset, and to become a leading global health service company we need to ensure we have the right talent in every role. We encourage internal career development and the opportunity to work in different areas of our business
- Relevant Work Experience: 2-3 years Customer Service and Claims experience required
- Educate providers by instructing and advising of the comprehensive policies and procedures involving all phases of the corporation''s benefits and contracts through office visits and communication over the phone and email
10
Responsibilities For Healthcare Provider Relations Representative Maine Resume
- Establish working relationships and collaborate with office staff in executing contracts and adhering to benchmarks set forth in all value based programs
- Enhance the development of the Optum’s suite of technology products, specifically RxClaim
- Work together with providers and office staff to ensure compliance with Beacon's requirements and expectations
- Monitor practice performance to ensure compliance with all contractual agreements, identify any barriers and make recommendations for corrective action plans and other interventions as required
- Review departmental and personal goals on an on-going basis with Director of Provider Relations
- Assist and / or lead tactical projects focused on customer satisfaction and implementation, and streamlining department processes
- Addresses escalated issues and problems affecting provider reimbursements
- Communicates to internal constituents regarding critical issues that impact the providers’ overall performance and satisfaction
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