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Provider Relations Representative skills for your resume and career

Updated January 8, 2025

5 min read

Below we've compiled a list of the most critical provider relations representative skills. We ranked the top skills for provider relations representatives based on the percentage of resumes they appeared on. For example, 15.5% of provider relations representative resumes contained customer service as a skill. Continue reading to find out what skills a provider relations representative needs to be successful in the workplace.

15 provider relations representative skills for your resume and career

1. Customer Service

Customer service is the process of offering assistance to all the current and potential customers -- answering questions, fixing problems, and providing excellent service. The main goal of customer service is to build a strong relationship with the customers so that they keep coming back for more business.

Here's how provider relations representatives use customer service:

Manage Provider Database-Verify and Load Contract Discounts-Update Physician Credentials-Maintain Contract Files-Support MedCheck Analysts-Customer Service
Coordinated resources to ensure excellent customer service; works collaboratively with Provider Relations management team to develop and implement strategic initiatives.

2. Provider Relations

Here's how provider relations representatives use provider relations:

Provide job training and mentoring on policies and procedures to new Provider Relations Representatives, Beneficiary Services Representatives and Clinical Liaison.
Developed Specific Position Orientation Training (SPOT) for provider relations representatives and other special projects for the Provider Relations Manager.

3. Medicaid

Here's how provider relations representatives use medicaid:

Completed new provider/office orientation for primary care, specialty physicians, and ancillary providers for Medicaid and Medicare products lines.
Created temporary medical identification numbers for new members to access the Medicaid website to find providers in network based location.

4. Patients

Here's how provider relations representatives use patients:

Worked as a Referral Coordinator to gather medical information from patients to qualify them for extended maternity stays.
Verified prescription eligibility with workers compensation insurance carrier; updates patients file accurately according to adjusters' instructions.

5. Health Plan

Here's how provider relations representatives use health plan:

Coordinate and conduct bi-annual educational seminars regarding health plan programs, utilization and quality management procedures, and complex reimbursement arrangements.
Marketed and facilitated all aspects regarding online product, providing instant access to health plan information including claims research and eligibility.

6. PowerPoint

Here's how provider relations representatives use powerpoint:

Developed and prepared PowerPoint presentations and ensured quality of brochures and pamphlets for presentation exhibits.
Schedule and conduct quarterly provider meetings for providers of BHRS, FBMHS and STAP which includes developing and presenting PowerPoint presentations.

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7. Issue Resolution

Issue resolution refers to a set of processes that can be used to resolve an issue, conflict, dispute, or claim, and the ability to deal with the problems that need to be resolved, the decisions that need to be made, and the risks that need to be mitigated. Essentially, an issue resolution process intends to make it easier for people to come to a resolution following an issue.

Here's how provider relations representatives use issue resolution:

Based on provider feedback, collaborate with internal departments on provider issue resolution and effectively communicate back to the provider community.
Monitored activities related to contract implementation; claims issue resolution, electronic data interchange and other provider service issues.

Select Skills To Add To Your Resume

Customer Service

Provider Relations

Medicaid

Patients

Health Plan

PowerPoint

8. Network Development

Network development is the process of scaling, developing and automating digital networks so that companies can process data more efficiently. Network development is generally carried out by a network engineer.

Here's how provider relations representatives use network development:

Provided administrative support to the VP of Network Development including creating/updating spreadsheets, preparing correspondence, and scheduling meetings.
Targeted providers for network inclusion based on network development strategy and complete contracts -- including discount rate negotiations.

9. Provider Issues

Here's how provider relations representatives use provider issues:

Served as point of contact for other internal departments regarding provider issues that impacted the provider directory and participation status.
Collaborate and effectively work with internal Arcadian/Arkansas Community Care departments to resolve provider issues and resolve member appeals and/or grievances.

10. Data Entry

Data entry means entering data into a company's system with the help of a keyboard. A person responsible for entering data may also be asked to verify the authenticity of the data being entered. A person doing data entry must pay great attention to tiny details.

Here's how provider relations representatives use data entry:

Recruited and enrolled contractors into the network; credentialed providers to ensure program requirements/quality control; basic data entry.
Performed data entry and conducted database analysis.

11. CPT

CPT is a medical term that stands for Current Procedural Terminology. Whenever a procedure like surgery or diagnosis occurs or some other medical service is rendered to a patient, it is reported to the concerned physician, insurance company, or organization. The aforementioned practice is widely referred to as CPT.

Here's how provider relations representatives use cpt:

Educate network providers regarding Claims Check software used for claims adjudication based ICD-9 & CPT code relationships as well as modifiers.
Keep Physician offices up to date on any new changes on contracted insurance providers, CPT codes and exams.

12. Fee Schedules

Here's how provider relations representatives use fee schedules:

Worked directly with providers for verification of credentialing to ensure accurate fee schedules based on demographics, provider specialty and contract.
Processed new provider contracts including credentialing providers maintained database of providers and fee schedules.

13. Claims Processing

Claims Processing is the entire workflow involved within the insurance company to evaluate a claim before it gets approved. It has many administrative layers such as assessing insurance eligibility, investigating the medical treatments taken, and reviewing medical codes before it settles or denies a claim with the insured healthcare provider.

Here's how provider relations representatives use claims processing:

Documented and resolved escalated complaints regarding claims processing, customer discontent regarding payment and denial explanations.
Managed provider file to ensure accuracy of information obtained and entered into system for claims processing.

14. Appeals

Here's how provider relations representatives use appeals:

Resolved escalated Grievance and Appeals medical issues and escalated adjudicated claims issues.
Review and research of appeals related to adverse benefit determinations.

15. Medicare Advantage

Here's how provider relations representatives use medicare advantage:

Managed Medicare Advantage Physician Network by developing and maintaining positive relationships in multiple counties throughout Middle Tennessee that increased provider satisfaction.
Secured significant percentage of ancillary providers for Mountain State Traditional/PPO/POS and Medicare Advantage networks, maintaining ongoing provider communication.

12 Provider Relations Representative Resume Examples

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Jeremy Hunter Provider Relations Representative Contact Information Parksdale, CA (820) 555-0369 jhunter@example.com Skills • Internet • Communication • Computer System • Dental Insurance • Insurance Companies • Facets • Provider Relations Representatives • Customer Retention • Legal Liability • Facilitate Training Employment History Provider Relations Representative 2018 - Present Anthem Parksdale, CA • Assisted in the design and implementation of solutions to provider issues and problems. • Continue educate myself to understand Medicare market so I can inform and educate Medicare prospects. • Achieved and selected as a best Medicare sales consultant in 2nd quarter. • Operate a PC/image station to obtain and extract information; documents information, activities and changes in the database. Claim Specialist 2017 - 2018 Kaiser Permanente San Francisco, CA • Researched accounts and performed necessary outreach to guarantors, insurance companies and attorneys to ensure timely, accurate payments. • Use health connect to check members history and verify authorization from doctors and nurses Medicare Part D Pharmacy Mental Health Claims • Appointed as Lead Trainer for new employees to Kaiser Permanente Claims Department. • Assigned ICD-9 code(s) to claims(s). • Determined proper policy coverage, and where necessary, investigated, evaluated, negotiated and settled all assigned liability claims cases. Insurance Verification Specialist 2012 - 2017 McKesson San Francisco, CA • Contract assignment as Reimbursement/Insurance Verification Specialist working with physicians, patients, and insurance companies. • Perform HCP and patient registration activities, according to program protocols and applicable departmental procedures. • Called multiple insurance companies to verify benefits and eligibility. • Place outgoing calls to insurance companies to verify insurance was current, and covered the specific items that were being ordered. Education High School Diploma 2006 - 2006


Jonathan Miller Provider Relations Representative Contact Info Jessup, MD (390) 555-0942 jmiller@example.com Skills Potential CustomersDaily NewspaperInternal DepartmentsProduct PlacementMarket ResearchSales AgentsSales GoalsProject ManagementProvider Relations RepresentativesCustomer Relations Employment History Provider Relations Representative 2020 - Present Aetna Jessup, MD • Conduct focused medical chart reviews and on-site visits for annual recertification of providers, as well as HEDIS and NCQA reviews. • Maintain provider data in support of claim adjudication and directory accuracy. • Assisted clients in resolving claims issues. Marketing Representative 2010 - 2020 Aflac Jessup, MD • Generated list of prospective clients and cold calling. • Executed sales and marketing strategies that consistently exceeded expectations and sales goals. • Define and facilitate core business development activities within selected sectors. Sales/Marketing 2007 - 2010 Sysco Minnesota Jessup, MD • Assessed and interpreted customer verbal and non-verbal communication to escalate sales and further develop and nurture relationships. • Credited with building a strong sales organization and increasing company profits by consistently meeting or exceeding aggressive sales goals. • Achieved daily, weekly, monthly and quarterly sales goals through face-to-face and telephone sales and marketing techniques. • Received phone and Internet orders, affording all customers with a high level of product knowledge and honesty. Education Bachelor's Degree Criminal Justice 1999 - 2002 American University Washington, DC


Ann Cole Provider Relations Representative Charlotte, NC acole@example.com (970) 555-8438 Experience Provider Relations Representative 2016 - Present Bank of AmericaCharlotte, NC • Reconciled 1500+ customer accounts within 3 months. • Collected funds from foreign banks and credited customer accounts. • Utilize high volume equipment to process, sort and reconcile a high volume of coin deposits. Claim Specialist 2015 - 2016 Blue Cross Blue Shield of TexasColumbia, SC • Processed medical claims in a timely manner Reviewed medical records Outbound calls to various physician to verify claims • Verified accident facts and reviewed policy coverage to determine legal liability of automobile claims. Insurance Verification Specialist 2005 - 2015 USAASan Antonio, TX • Assisted departments in such areas as file distribution, incompletion and withdrawal, member communication, requirement fulfillment and beneficiary updates. • Collaborated with team members to exchange ideas and to develop appropriate solutions to improve communication with the customers. • Follow up with insurance companies for claim status, verified benefits and eligibility. Skills Provider Issues Facets Sales Goals Patient Demographics Provider Orientations Insurance Companies Medicaid State Plan Provider Data Issue Resolution Education High School Diploma 1999 - 1999


Judy Sanders Provider Relations Representative Employment History Provider Relations Representative 2020 - Present TeamHealthKnoxville, TN • Utilized Internet email as an effective communication tool. • Assisted in the design and implementation of solutions to provider issues and problems. • Negotiated complex contracts with individual providers, practice managers and health care systems. Pharmaceutical Sales Representative 2019 - 2020 Johnson & JohnsonKnoxville, TN • Worked within pods to maximize product knowledge and team result driven expertise. • Focused on increasing market share growth on three pharmaceutical products. • Recognized for increasing market share of Concerta from 28% in Q1 to 31% in Q2, 2007. • Finished #1 in region of 76 for lead product market share growth. • Created alternative business plans to improve customer relationships. • Earned national ranking of #5 for entire year of Aciphex market share growth in '03. Retail Sales Representative 2017 - 2019 U.S. CellularKnoxville, TN • Received a 100% on several customer service performance reviews. • Used a five-step sales process to present customers with suitable wireless products and services to achieve superior results and upsell. • Participated in Sales Strategic training for retail sales and marketing in sales channel. • Retail sales, cold calling and email contact with prospects and existing customers. • Front line retail sales, Upgrading customers devices, Introduced customers to new and upcoming promotions. • Process cash transactions and deposits; balance POS stations Contribute to business unit opening and closing exercises. Education High School Diploma 2017 - 2017 Contact Information Knoxville, TN (850) 555-6189 jsanders@example.com Skills New Devices Product Sales Retail Sales Wireless Products Medical Community Customer Service Product Expertise Direct Reports Revenue Growth Internal Departments


Martha Miller Provider Relations Representative New York, NY (580) 555-3610 mmiller@example.com Skills Company Standards Icd-9 Contract Negotiations Facets RFQ Medicaid Claims Processing Idiq Health Care Special Projects Employment History Provider Relations Representative 2018 - Present CitiNew York, NY • Recorded feedback and results from customer interactions. • Assist in connecting and troubleshooting conference room equipment including projectors, telephone and communication systems. • Promote products and services to health care professionals in a consistent and compliant manner. • Negotiated pricing and problem resolution with vendors and customers for win/win results. Contracts Specialist 2017 - 2018 Allianz LifeEagan, MN • Conducted special projects and taking lead on high profile customer groups. • Counseled business units on contractual rights, issues and obligations and conducted risk/benefit analysis of existing and new technologies. • Review RFP and RFQ for vendors with an interest in services within the organization. • Negotiated and prepared Personal Service Contracts (PSC's). • Purchased merchandise and professional services, negotiated low prices, prepared purchase orders, solicited bids, and reviewed requisitions. Customer Relations Representative 2007 - 2017 West AcademicEagan, MN • Use product knowledge to upsale accounts. • Resolved customer inquiries and complaints using inbound and outbound communication methods. • Executed Extraordinary Customer Care during Phone Interactions Resulting in Measurable Card Member Value. • Trained staff on how to improve customer interactions. Education High School Diploma 2007 - 2007


Jesse Gomez Provider Relations Representative Lafayette, LA (980) 555-7569 jgomez@example.com Experience: Provider Relations Representative AT&T Lafayette, LA 2019 - Present • Lead Support for best customer retention site for over two years. • Initiated 125-300 telephone calls per day for the purpose of selling and servicing Yellow Pages internet and print advertising. • Record and maintain fully-stocked sales floor. • Managed customer accounts and provided retention offers, to keep customers from leaving to competitors. Intake Coordinator Halliburton Lafayette, LA 2018 - 2019 • Remained available 24/7 to assist relief personnel, ensuring no details missed on alternate shifts and all customer communication immediately attended. • Utilized technical and/or operational expertise to provide service delivery solutions for customers. • service delivery solutions for customers. • Managed multiple teams responsible for service delivery of jobs valued at $5-10K per day per location. Referral Specialist MetLife Bridgewater, NJ 2015 - 2018 • Perform standard communication (phone calls, emails, and letters) to appropriate parties throughout the duration of the leave. • Assist with answering telephones, scheduling patients to see our physician's, assist with medical records and filing charts. • Operate telephone switchboard to answer, screen, or forward calls, providing information, taking messages, or scheduling appointments. Skills • Medical Records • Customer Service • EKG • Intake Process • Background Checks • Insurance Companies • Treatment Plans • Provider Issues • Medical Facilities • Insurance Forms Education: Some College Courses DeVry University Oakbrook Terrace, IL 2010 - 2010 • Major: Health Care Administration


Amber Carter Provider Relations Representative Charlotte, NC (210) 555-3736 acarter@example.com Experience: 2019 - Present Provider Relations Representative / Wells Fargo / Charlotte, NC • Investigate and resolve wide-array of customer complaints and inquires, ensuring highest level of satisfaction. • Audited current and former customer accounts to ensure accurate reporting to credit bureaus. • Serve as a source of information and support between the provider community and the company. • Promote products and services, fulfill customer requests and ensure customer retention and satisfaction. • Resolved customer complaints and facilitated appropriate action. 2016 - 2019 Insurance Specialist / Primerica / College Park, MD • Lead team in patient account reconciliation. • Contacted insurance companies (nationwide/regional carriers) for clarification of patient coverage if needed. • Verified daily receipts, prepared bank deposits. 2014 - 2016 Insurance Representative / Allstate / College Park, MD • Assisted in agent s office from call center still within Allstate Insurance Company. • Awarded for daily challenges and highest in customer service percentages for team per quarter. • Endorse all checks immediately upon receipt with a restrictive Allstate endorsement. • Provided excellent customer service and built excellent relationship with the customers. • Directed myriad projects with multiple insurance companies; learned the business comprehensively. Skills: Sales Floor, Communication, Insurance Companies, Navinet, Special Projects, Fee Schedules, Claims Submission, Claims Processing, Walk-In Customers, Patient Demographics Education: 2006 - 2009 Bachelor's Degree Political Science / University of Maryland - College Park / College Park, MD


David Holmes Provider Relations Representative Blue Bell, PA \| (220) 555-2831 \| dholmes@example.com Work Experience Provider Relations Representative, Aetna - Blue Bell, PA 2020 - Present Run weekly internal department meetings for the Provider reps, Administrators, MDs, and Nurses. Recruited new providers to Aetna's Commercial and Medicare lines of business. Answered questions and resolved issues based on phone calls, from providers and plan sponsors via oral communication. Have participated in annual Medicaid Forums and conducted presentations at provider seminars. Received incoming information, including medical records, for categorizing, review, and resolution. Identify top providers for on-site marketing opportunities and collaborate with the Medicare and Medicaid outreach representative. Claim Processor, Nationwide Mutual Insurance ... - Harrisburg, PA 2015 - 2020 Clear proper policy coverage, investigate and resolve coverage issues as needed. Initiated contact on auto claims, evaluated repairability of vehicles. Investigated claims for SIU referrals. Maintained files and kept positive communication with customers on the status of the claim. Completed Casualty Claims New Hire Field School giving me hands on knowledge of determining liability and settling auto claims. Connected with company managers personally, and held teleconferences with multiple stakeholders to enable open communication and problem-solving. Provider Services Representative, Aetna - Hartford, CT 2013 - 2015 Explain health care provider contract and policy parameters Transcribe recorded messages and practitioners' diagnoses and recommendations into patients' medical records. Obtain necessary information required for reviewing prior authorization through insurance companies. Skills Policy Coverage, Patient Accounts, Medicare, Provider Information, Provider Issues, Medical Records, Problem Resolution, Provider Contracts, Secondary Claims, Health Care Education High School Diploma 2008 - 2008


Donna Spencer Provider Relations Representative Albany, GA (810) 555-5253 dspencer@example.com Experience Provider Relations Representative, Teleperformance, Albany, GA 2017 - Present • Handled customer complaints, processed orders, and provided information about Comcast's products and services. • Serve as SME liaison for health care providers and the government of the District of Columbia. Billing And Insurance Coordinator, Landauer, New York, NY 2016 - 2017 • Assist with the construction and feedback of the department systems and procedures. • Maintained appointment schedules and patient medical records for several Cardiologists. • Front and back office procedures including medical records and handling phone multiple phone lines. • Provide data and assistance to mortgage insurance companies to expedite claims settlement. Customer Service And Billing, Domino's Pizza, New York, NY 2015 - 2016 • Answer incoming telephone calls Process orders efficiently Keep area clean and tidy Arrange store displays Answer customer inquiries Operate cash register • Learned, referenced and applied product knowledge information. • Handled all cash registers * Greeting Customers * Stocking * Sales • Maintained on-going customer relationships, educated customers on options such as special forbearance, modifications, short sales, and foreclosures. Skills • Provider Relations Representatives • Medicaid • Insurance Companies • Hard-Working • Secondary Claims • Medical Records • MSP • Claims Processing • Retail Sales • External Customers Education 2015 - 2015 High School Diploma


Ethan Green Provider Relations Representative Kansas City, MO \| (900) 555-2024 \| egreen@example.com Employment History: Boston Financial Data Services - Kansas City, MO 2018 - Present Provider Relations Representative • Processed customer accounts in response to written or verbal request. • Verified documents had the correct legal documentations necessary for customer accounts. • Field Representative in Arizona region for Medicare Advantage insurance provider. • Review medical insurance claims denials and approvals Explained member's health care benefits to providers as well as patients. Assurant - Kansas City, MO 2016 - 2018 Reimbursement Specialist • Prioritized assignments and had keen ability to multi-task communication. • Conducted daily call outs to homeowners and insurance companies to request additional information needed to process the claim. • Maintained communication with all levels within and outside of the organization. Farmers Insurance - Oklahoma City, OK 2014 - 2016 Insurance Representative • Oversee all Customer Service Representatives in daily aspects of the job. • Developed business plan for my own agency Prospecting for new accounts using various techniques. • Process payments, endorse policies and provide insurance with great customer service with a smile. • Provided customer service to property and casualty clients. Skills: Delinquent Accounts, Medical Records, Benefit Investigations, Claims Submission, Financial Statements, Appropriate Products, Medicare, Insurance Options, Business Development, Fee Schedules Education: Georgia State University - Atlanta, GA 2006 - 2009 Bachelor's Degree Insurance


Jacob Cook Provider Relations Representative phone(920) 555-6269 addressChicago, IL emailjcook@example.com Experience 2017 - Present Provider Relations Representative TTC · Chicago, IL • Recommended prospective providers for submission to the Network Development Department. • Handle special projects as assigned for state and department inquiries. • Trained Health and Welfare staff on Medicaid Modernization, CHIP, NPI/HIPAA. • Maintained constant communication with the manager to ensure customer safety. 2010 - 2017 Benefit Specialist Apple · Chicago, IL • Attended every supplemental training session to further my product knowledge. • Enriched customers lives through building relationships, talking Apple, providing excellent customer service and an overall great customer experience. • Generated the energy and excitement around Apple products, transformed Apple store visitors into customers. • Introduce prospective accounts to the various business opportunities available through Apple. 2009 - 2010 Verification Specialist Apple · Chicago, IL • Have sold millions per year for apple every year. • Maintained the Apple Shop in Shop in accordance with Apple standards. • Assist on visual overnight resets for the sales floor, including imaging of new products for display. Skills • Long-Term Disability • Issue Resolution • Personnel Files • Facets • Staff Members • Life Events • Health Care • Medicaid • Educational Materials • Escalate Education 2004 - 2004 Some College Courses Business DeVry University · Oakbrook Terrace, IL


Terry Robertson Provider Relations Representative phone:(390) 555-8659 email:trobertson@example.com address:Houston, TX Employment History Provider Relations Representative 2015 - Present Comcast · Houston, TX • Served as support supervisor to 18 newly trained customer relations representatives. • Use proven sales techniques and creativity to sell Comcast Video, High Speed Internet, and Comcast Digital Voice. • Utilized company software and technical knowledge to troubleshoot internet and cable issues for customers over telephone. Insurance Specialist 2014 - 2015 Aegis Communications Group · Dallas, TX • Recorded and filed patient data and medical records. • Assist with campaign regarding Humana, United Health Care and Right Source. • Processed credit card payments as well as update contact information. • Attended Hugo Boss conclave for Nordstrom gaining product knowledge and direction for the company. Insurance Representative 2013 - 2014 State Farm · Dallas, TX • Provided customer service for agency including sales with P/C, life, health and long term care policies. • Process claims for home and auto insurance. • Pivoted into additional insurance needs when handling daily customer service issues.\ • Maintain customer accounts and bring in new customers. • Marketed appropriate products and services. Skills Physician Offices Facets Patient Demographics Complex Issues Issue Resolution Claims Processing Company Policies Insurance Companies Customer Retention Income Education High School Diploma 2008 - 2008

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List of provider relations representative skills to add to your resume

The most important skills for a provider relations representative resume and required skills for a provider relations representative to have include:

Customer Service
Provider Relations
Medicaid
Patients
Health Plan
PowerPoint
Issue Resolution
Network Development
Provider Issues
Data Entry
CPT
Fee Schedules
Claims Processing
Appeals
Medicare Advantage

IPA
Problem Resolution
HMO
CMS
Claims Issues
Outbound Calls
Provider Inquiries
Provider Contracts
PPO
ICD-9
EDI
Medical Claims
NCQA
Facets
Inbound Calls

Network Adequacy
Provider Community
Educational Materials
Provider Data
Tricare
Claims Resolution
Provider Complaints
Provider Satisfaction
Billing Issues
Contract Negotiations
Hippa
Physician Recruitment
Contract Issues
Cactus
Cigna

Updated January 8, 2025

Zippia Team

Editorial Staff

The Zippia Research Team has spent countless hours reviewing resumes, job postings, and government data to determine what goes into getting a job in each phase of life. Professional writers and data scientists comprise the Zippia Research Team.

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Provider Relations Representative Skills

Updated January 8, 2025

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