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Become A Provider Relations Representative

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Working As A Provider Relations Representative

  • Getting Information
  • Interacting With Computers
  • Communicating with Persons Outside Organization
  • Communicating with Supervisors, Peers, or Subordinates
  • Establishing and Maintaining Interpersonal Relationships
  • Deal with People

  • Mostly Sitting

  • Repetitive

  • $31,720

    Average Salary

What Does A Provider Relations Representative Do At Cigna

* 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.
* 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.
* Additional responsibilities include: conducting root cause analysis and resolution of provider concerns, participating in monthly financial review with senior management and partnering with other internal departments, including but not limited to Health Services, Medical Economics, Sales, and Coding in order to develop solutions for strategic business needs

What Does A Provider Relations Representative Do At Accenture

* Conduct face to face scheduled and unscheduled visits within the provider community
* Maintain a working knowledge of Medicaid program and policy, online provider resources, and internal processes and technological applications
* Provide on demand education and policy/procedural information to provider community as well as internal/external stakeholders
* Coordinate and conduct orientations and training for newly enrolled, as well as established, providers
* Research provider claims and Medicaid policy
* Document of all provider/external stakeholder communications
* Manage local territory through utilizing internal job aids and resources
* Meet all contractual obligations while establishing and maintaining positive interpersonal relations among stakeholders
* Develop interpersonal relationships with peers and workgroups while working remotely
* Participate in team training and workgroups in addition to individual territory responsibilities

What Does A Provider Relations Representative Do At Unitedhealth Group

* Comprehends Provider contracts, is able to determine capitation terms and effectively incorporate changes and / or updates for configuration.
* Appropriately tests all changes for accuracy and implements into the cap process Identify and configure necessary additions, changes and deletions to new and existing configuration design as it relates to capitation Originates scheduling of pre-cap/ post-cap calculations and capitation reports.
* Coordinates report extractions with Business Analyst and team members.
* Identifies variances and issues, analyzes and implements data for review, communicates issues and receives approvals from Executive Directors Ensures accuracy of data on Excel spreadsheets by verifying proper linking.
* Audits raw data, compares with worksheets to verify proper PCP / Specialty cap calculations.
* Generates and submits PCP / Specialty cap payment upload requests to Accounts Payable for processing Works with Lead, Business Analysts and Manager, in troubleshooting system and reporting or process issues.
* Must be able to effectively analyze issues and communicate problem-solving ideas Reconciles PCP / Specialty cap expense to general ledger.
* Generates cap related reports to perform PCP / Specialty audits, adjustments, check requests, analyses, research and special projects, as required Collaborates with the IS staff in developing and testing of system upgrades Utilizes various computer programs to research provider, member and eligibility information

What Does A Provider Relations Representative Do At Sanford Health

* Duties include oversee data entry and training of new enrollment employees for the provider network database.
* Initiates database improvement efforts and represents the provider enrollment area on IT projects.
* Develop and produce reports for Provider Relations Manager and Provider Relations Director.
* Develop and maintain standards for database integrity.
* Coordinates maintenance activities for the provider database.
* Manages communication with other departments regarding database improvements.
* Responsible for obtaining provider profile information; this includes verifying provider demographic, billing, credentialing, and etc. information from providers in a timely manner.
* Entering provider enrollment and disenrollment data and maintaining the provider access database.
* Coordinate with the central verification office and management to resolve operational issues or provider profile discrepancies.
* Knowledge of credentialing requirements is useful.
* Skill in using office machines-fax, computer and copier.
* Ability to examine documents for accuracy and completeness.
* Ability to establish priorities and coordinate work activities.
* Ability to maintain confidentiality of sensitive information.
* Ability to communicate clearly and concisely.
* Ability to work effectively with central verification office, provider office staff and internal health plan staff

What Does A Provider Relations Representative Do At Rush University Medical Center

* Maintain relationships with Participating Hospital and Physician Members regarding revenue cycle and payer compliance activities
* Schedule and maintain quarterly meetings with Participating Hospital Members for operational support and ongoing education.
* Support Network Development staff in advising Participating Physician Members regarding Rush Health third party payer contract terms and compliance issues.
* Serve as primary liaison between Participating Hospital and Participating Physician Members and third party Commercial, Value Based, Medicare Advantage, and Managed Medicaid payers to provide support in resolution of operational and claims issues.
* Manage and facilitate monthly payer meetings to include creating agendas and maintaining minutes and follow-up on action items from the meetings.
* Work with third party payers to ensure new Rush Health Members are loaded in the payer system and attached to Rush Health contracts and pricing.
* Assist Contracting and Payer Relations in tracking and resolution of outstanding payer compliance issues including root cause identification and remediation.
* Develop and present educational materials and educational sessions for Members regarding third party payer contract terms, operational processes and payer market changes.
* Co
* Manage and facilitate distribution of internal contract compliance reports and utilize as a mechanism to develop standard solutions to common revenue cycle issues.
* Facilitate centralized and aggregate approach to payment remediation efforts.
* Maintain and update the "designated" fields for physicians and hospitals in Contract Summaries

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How To Become A Provider Relations Representative

Customer service representatives typically need a high school diploma and receive on-the-job training to learn the specific skills needed for the job. They should be good at communicating and interacting with people and have some experience using computers.


Customer service representatives typically need a high school diploma.


Customer service representatives usually receive short-term on-the-job training, lasting 2 to 3 weeks. Those who work in finance and insurance may need several months of training to learn more complicated financial regulations.

General customer-service training may focus on procedures for answering questions, information about a company’s products and services, and computer and telephone use. Trainees often work under the guidance of an experienced worker for the first few weeks of employment.

In certain industries, such as finance and insurance, customer service representatives must remain current with changing regulations.

Licenses, Certifications, and Registrations

Customer service representatives who provide information about finance and insurance may need a state license. Although licensing requirements vary by state, they usually include passing a written exam. Some employers and organizations may provide training for these exams.

Important Qualities

Communication skills. Customer service representatives must be able to provide information in writing, by phone, or in person so that customers can understand them.

Customer-service skills. Representatives help companies retain customers by answering their questions and complaints in a helpful and professional manner.

Interpersonal skills. Representatives should be able to create positive interactions with customers.

Listening skills. Representatives must listen carefully and understand a customer’s situation in order to assist them.

Patience. Representatives should be patient and polite, especially when interacting with dissatisfied customers.

Problem-solving skills. Representatives must determine solutions to a customer’s problem. By resolving issues effectively, representatives contribute to customer loyalty and retention.

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Provider Relations Representative jobs

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Provider Relations Representative Demographics


  • Female

  • Male

  • Unknown



  • White

  • Hispanic or Latino

  • Asian

  • Unknown

  • Black or African American

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Languages Spoken

  • Spanish

  • French

  • Portuguese

  • Carrier

  • German

  • Chinese

  • Hebrew

  • Russian

  • Cantonese

  • Mandarin

  • Italian

  • Vietnamese

  • Greek

  • Kannada

  • Hindi

  • Korean

  • Thai

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Provider Relations Representative

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Provider Relations Representative Education

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Top Skills for A Provider Relations Representative


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Top Provider Relations Representative Skills

  1. Provider Relations
  2. Medicaid
  3. Health Plan
You can check out examples of real life uses of top skills on resumes here:
  • Answered queue phone calls regarding claim issues, provider participation or any other request for information for provider relations.
  • Provide direct contact with Medicaid Insurance Providers to ensure accuracy of payments and credentialing services.
  • Research, interpret and communicate contractual terms and conditions for both interdepartmental, Health Plan and other provider inquiries.
  • Managed a territory with over 3500 physicians, 12 medical groups, and 6 hospitals.
  • Introduced Medicare Advantage program in St Johns County and responsible for contracting providers and membership enrollment.

Top Provider Relations Representative Employers

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