Provider Relations Representative

Direct Hire Portland, Maine

The Provider Relations Representative has primary responsibility for maintaining provider networks that deliver clinical, financial, and service value to members and acts as the departmental point of contact for internal and external customer relations. In partnership with Network leadership and the Network Management team, this role is responsible for maintaining ongoing positive relationships with contracted providers (network management) and managing the day-to-day internal work which includes the Network Management Provider email inbox, incoming faxes, prepping and QC of our provider contracts, and scanning and maintaining all department standard work and policies to ensure compliance.

Key Outcomes:

  • Collaborates with Network Representatives and Senior Network Representatives to identify potential providers (by market, by specialty) including gap analysis for all network expansion work
  • Collaborates with Network Representatives, Senior Network Representatives, and the Manager Network Management to recruit new providers in existing markets and new expansion areas
  • Acts as a liaison between internal departments to establish policies and procedures to maximize workflows
  • Identifies system and processing enhancements for Claims, HMD, Provider Inquiry, and Member Services
  • Maintains customer service tracker (specific to operational issues between claims, member services, provider inquiry) in coordination with customer service to enhance provider and member satisfaction
  • Assists Network Representatives and Senior Network Representatives with preparation and presentation of departmental or plan audits and reviews, (e.g., CMS, TRICARE, Medicare)
  • Assists with claim inquiries as it relates to provider complaints and tracks complaints into our contract system
  • Maintains relationships with network providers to promote positive relationships and ensure contract compliance
  • Provides education to providers through in-person visits, webinars, outreach calls or email
  • Partners with Sales Team to contract with requested providers to achieve strategic member enrollment goals
  • Communicates with providers to address and resolve complaints and other specific issues
  • Researches and resolves Health Plan grievances presented by providers within accepted departmental timeframes to maintain compliance
  • Facilitates improved workflows within the department and cross functionally
  • Maintains updates to our internal process manual and employee training manual
  • Ensures all provider applications are accurately completed and prepared for processing by Credentialing by ensuring provider CAQH status is current and up to date as appropriate with new/recredentialing provider applications
  • Performs onsite credentialing site visits
  • Supports overall Network Management production work as needed (e.g., entering provider changes)

Education/Experience:

  • Bachelor’s degree or equivalent combination of education and work experience
  • 2+ years of experience in an administrative and/or customer service position required with experience in provider contracting and network management preferred

Required License(s) and/or Certification(s):

  • Valid driver’s license (no restricted or suspended license)

Required Skills:

  • Proficiency in Microsoft Word, Excel, and Access Office Products
  • Excellent interpersonal and communication skills (both oral and written)
  • Ability to organize and execute multiple activities simultaneously
  • Problem-solving skills
  • Demonstrated and evaluated ability to work independently to meet goals
  • Strong collaboration skills
  • Ability to collect and manipulate data and develop presentation
  • Ability to travel up to 5% of the time with potential overnights

 

 

Apply to: Provider Relations Representative

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ProSearch is Maine’s premier staffing and recruiting firm. Our job is to connect great people with great opportunities. Established in 1994, ProSearch helps Maine’s top employers build their teams by recruiting just the right people – from temp/temp-to-hire, to IT consulting, to direct hire- for just the right positions.

ProSearch is proud to be an affirmative action/equal opportunity employer. All qualified applicants will receive consideration without regard to race, creed, gender/sex, marital status, sexual orientation, citizenship status, color, religion, national origin, age, disability, veteran status, or any other status protected under local, state or federal laws.

Apply to: Provider Relations Representative

Attach a resume file. Accepted file types are DOC, DOCX, PDF, HTML, and TXT.

We are uploading your application. It may take a few moments to read your resume. Please wait!