What does a provider services representative do?
A provider services representative is responsible for supporting, developing, and maintaining service relationships with involved participants, including providers, physicians, and administrators. Your duties typically include responding to direct and electronic questions from clients about rates, policies, referrals, and eligibility, handling telephone calls for the provider and member inquiries, and resolving complaints by the member and member representative. In addition, you will be assisting in collecting supporting data and documentation about the member's care. You are also expected to conduct research to be able to provide a well-informed answer to members' inquiries.
Provider services representative responsibilities
Here are examples of responsibilities from real provider services representative resumes:
- Coach, evaluate and performance manage MSRs to ensure timely and accurate service to clients.
- Achieve excellent customer satisfaction ratings as documented by CIGNA surveys.
- Proof reading contracts in order to adjust claims according to proper DRG, ICD-9, and CPT codes.
- Complete the surgery schedule and ensure all patients are aware of their financial responsibility prior to the surgery date.
- Help providers with all information about CPT codes such as authorizations, restrictions, fee schedules, and correct diagnosis codes.
- Register patients for surgery in computer system.
- Update member information and provide customer satisfaction while informing patients of medical benefits and reprocessing deny medical claims.
- Provide unbias assistance to Medicaid providers with questions regarding Medicaid patient eligibility, medical claims statuses, and other program questions.
- Receive daily admitting information from hospitals and compile hospital census data, including ICD-9 diagnosis codes.
- Claim resolution, EDI issues, appeal status, provider recruitment, and authorization or referral information.
- Update the ICD-9 codes for claims as directed by the billing offices of providers to allow the claims to process.
- Prepare and process of provider applications; upon receipt of provider number responsible for EDI enrollment and updating pending database.
- Maintain confidentiality and adhere to HIPAA regulations.
- Research and design PowerPoint presentations for physicians.
- Evaluate and review credentialing procedures per NCQA guidelines.
Provider services representative skills and personality traits
We calculated that 24% of Provider Services Representatives are proficient in Customer Service, Data Entry, and Patients. They’re also known for soft skills such as Computer skills, Customer-service skills, and Listening skills.
We break down the percentage of Provider Services Representatives that have these skills listed on their resume here:
- Customer Service, 24%
Provided navigational support and customer service for individuals providing home chore services to Medicaid recipients during their transition to paperless reporting.
- Data Entry, 6%
Utilized proprietary software for confidential clientele data entry, retrieval, and benefits and eligibility verification.
- Patients, 5%
Updated member information and provided customer satisfaction while informing patients of medical benefits and reprocessing denied medical claims.
- Medicaid, 5%
Verified Alabama Medicaid recipient insurance eligibility.
- Health Insurance, 4%
Educated inbound customer and provider calls utilizing company scripts to accurately describe benefits and medical policies of their health insurance.
- Appeals, 3%
Communicate with Providers and/or Representatives regarding appeals that do not meet criteria or other relevant provider issues.
"customer service," "data entry," and "patients" are among the most common skills that provider services representatives use at work. You can find even more provider services representative responsibilities below, including:
Customer-service skills. Many provider services representative duties rely on customer-service skills. "representatives help companies retain customers by professionally answering questions and helping to resolve complaints.," so a provider services representative will need this skill often in their role. This resume example is just one of many ways provider services representative responsibilities rely on customer-service skills: "assisted walk in customers with eob questions. "
Listening skills. Another skill that relates to the job responsibilities of provider services representatives is listening skills. This skill is critical to many everyday provider services representative duties, as "representatives must listen carefully to ensure that they understand customers in order to assist them." This example from a resume shows how this skill is used: "communicated with clients while receiving a high number of incoming calls on a daily basis regarding florida medicaid provider billing issues. "
Patience. provider services representative responsibilities often require "patience." The duties that rely on this skill are shown by the fact that "representatives should be patient and polite, especially when interacting with dissatisfied customers." This resume example shows what provider services representatives do with patience on a typical day: "answered any and all questions asked about the members medical policy skills used customer service, patience, and punctuality"
Problem-solving skills. A commonly-found skill in provider services representative job descriptions, "problem-solving skills" is essential to what provider services representatives do. Provider services representative responsibilities rely on this skill because "representatives must determine solutions to customers’ problems." You can also see how provider services representative duties rely on problem-solving skills in this resume example: "resolved claim issues and fee schedule request for providers by acting as liaison with other departments. "
Communication skills. Another skill commonly found on provider services representative job descriptions is "communication skills." It can come up quite often in provider services representative duties, since "customer service representatives must be able to provide clear information in writing, by phone, or in person." Here's an example from a resume of how this skill fits into day-to-day provider services representative responsibilities: "demonstrate effective listening skills *resolves claims issues *demonstrate effective oral and written communication skills. "
The three companies that hire the most provider services representatives are:
- Oracle147 provider services representatives jobs
- UnitedHealth Group14 provider services representatives jobs
- Molina Healthcare10 provider services representatives jobs
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Compare different provider services representatives
Provider services representative vs. Retention representative
Call center representatives are employees who take customer calls in the company's contact center. They answer incoming calls related to their account. Call center representatives are trained on the company's products, policies, and guidelines. They are expected to know the ins and outs of every company product under their account before they are assigned to the operations floor. Once they are deemed efficient enough to handle calls, they begin to take customer inquiries and try to resolve them during the call. Call center representatives are expected to follow company policies and procedures and to meet the goals set by the company.
These skill sets are where the common ground ends though. The responsibilities of a provider services representative are more likely to require skills like "data entry," "patients," "health insurance," and "appeals." On the other hand, a job as a retention representative requires skills like "product knowledge," "english language," "persuasion," and "csg." As you can see, what employees do in each career varies considerably.
Retention representatives really shine in the technology industry with an average salary of $47,247. Comparatively, provider services representatives tend to make the most money in the health care industry with an average salary of $34,112.retention representatives tend to reach similar levels of education than provider services representatives. In fact, retention representatives are 2.2% less likely to graduate with a Master's Degree and 0.2% less likely to have a Doctoral Degree.Provider services representative vs. Call center representative
An enrollment representative directly communicates with clients when it comes to enrollment programs. Although their duties vary on their place or industry of employment, it typically includes helping enrollees understand the program requirements and rules, reaching out to enrollees to provide updates, gathering and processing applications, answering inquiries, and collecting payments when necessary. They also perform clerical tasks such as preparing and processing documents, updating databases, and maintaining records. Moreover, an enrollment representative must maintain an active communication line with staff for a smooth and efficient workflow.
In addition to the difference in salary, there are some other key differences worth noting. For example, provider services representative responsibilities are more likely to require skills like "appeals," "cpt," "medical terminology," and "inbound calls." Meanwhile, a call center representative has duties that require skills in areas such as "strong customer service," "troubleshoot," "bartending," and "inbound phone calls." These differences highlight just how different the day-to-day in each role looks.
On average, call center representatives earn a lower salary than provider services representatives. Some industries support higher salaries in each profession. Interestingly enough, call center representatives earn the most pay in the finance industry with an average salary of $32,660. Whereas provider services representatives have higher pay in the health care industry, with an average salary of $34,112.call center representatives earn similar levels of education than provider services representatives in general. They're 3.1% less likely to graduate with a Master's Degree and 0.2% less likely to earn a Doctoral Degree.Provider services representative vs. Enrollment representative
A membership representative is responsible for assisting clients and customers with their inquiries and concerns and processing their membership requests for organizations and agencies. Membership representatives sell membership services to the customers, process their orders, and post their payments in the database. They also work closely with the sales and marketing team to develop promotional efforts and techniques that would invite more clients and increase revenues. A membership representative must have excellent communication and organizational skills, especially in interacting with customers and resolving their complaints.
There are many key differences between these two careers, including some of the skills required to perform responsibilities within each role. For example, a provider services representative is likely to be skilled in "medicaid," "appeals," "cpt," and "medical terminology," while a typical enrollment representative is skilled in "home health," "enrollment process," "transactional data," and "excellent interpersonal."
Enrollment representatives earn the highest salary when working in the non profits industry, where they receive an average salary of $35,222. Comparatively, provider services representatives have the highest earning potential in the health care industry, with an average salary of $34,112.enrollment representatives typically earn similar educational levels compared to provider services representatives. Specifically, they're 5.0% more likely to graduate with a Master's Degree, and 0.1% more likely to earn a Doctoral Degree.Provider services representative vs. Membership representative
Types of provider services representative
Updated January 8, 2025
