What does a Provider Relations Representative do?
Provider relations specialists are professionals who work for insurance companies as the primary contact for health care providers such as clinics and hospitals. These specialists are required to provide answers about service contracts and billing procedures to health care providers. They must handle the documents of patients to ensure that proper paperwork has been filed for coverage while developing communications with providers about any policy changes. Provider relations specialists must also travel to different health care organizations to provide training to their staff on insurance policies and procedures.
Provider relations representative responsibilities
Here are examples of responsibilities from real provider relations representative resumes:
- Help manage ACO program and review measures with provider offices.
- Advise clients on health care and manage care products including POS, PPO and medical management programs.
- Provide keen oversight in developing and maintaining quality improvement programs while managing payroll.
- Manage software maintenance renewal partner and assist with upselling additional and higher functionality licenses to increase revenue.
- Review the provider contracts, paid members claims, base on the CPT code & ICD-9 that are submitted.
- Review provider claims for CPT and ICD-9 coding accuracy and generate payment of claims base upon current fee schedule.
- Complete knowledge of HMO/PPO contracts, ICD-9, CPT-4 coding and medical terminology.
- Conduct site visits with physicians and various medical groups to ensure their compliance with state regulations for the HMO organization.
- Facilitate new office orientations, train staff and present program details and requirements about how to work with the HMO.
- Educate practices on quality metrics, integrate care model and gaps relate to chronic conditions require to meet CMS guidelines.
- Identify strategic health systems and establish relationships for contracting with them for new collaborative model of PPO product in WI.
- Verse in CPT-4 and ICD-9 coding, claims systems, Medicare RBRVS, third party billing, and technical support.
- Handle informal review appeals for providers and beneficiaries
- Complete CMS approve training and marketing certification.
- Review and research of appeals relate to adverse benefit determinations.
Provider relations representative skills and personality traits
We calculated that 16% of Provider Relations Representatives are proficient in Customer Service, Provider Relations, and Medicaid. They’re also known for soft skills such as Computer skills, Customer-service skills, and Listening skills.
We break down the percentage of Provider Relations Representatives that have these skills listed on their resume here:
- Customer Service, 16%
Manage Provider Database-Verify and Load Contract Discounts-Update Physician Credentials-Maintain Contract Files-Support MedCheck Analysts-Customer Service
- Provider Relations, 9%
Provide job training and mentoring on policies and procedures to new Provider Relations Representatives, Beneficiary Services Representatives and Clinical Liaison.
- Medicaid, 9%
Completed new provider/office orientation for primary care, specialty physicians, and ancillary providers for Medicaid and Medicare products lines.
- Patients, 6%
Worked as a Referral Coordinator to gather medical information from patients to qualify them for extended maternity stays.
- Health Plan, 5%
Coordinate and conduct bi-annual educational seminars regarding health plan programs, utilization and quality management procedures, and complex reimbursement arrangements.
- PowerPoint, 4%
Developed and prepared PowerPoint presentations and ensured quality of brochures and pamphlets for presentation exhibits.
"customer service," "provider relations," and "medicaid" are among the most common skills that provider relations representatives use at work. You can find even more provider relations representative responsibilities below, including:
Customer-service skills. Many provider relations representative duties rely on customer-service skills. "representatives help companies retain customers by professionally answering questions and helping to resolve complaints.," so a provider relations representative will need this skill often in their role. This resume example is just one of many ways provider relations representative responsibilities rely on customer-service skills: "document all incoming inquiries into respective customer or provider database. "
Listening skills. provider relations representatives are also known for listening skills, which are critical to their duties. You can see how this skill relates to provider relations representative responsibilities, because "representatives must listen carefully to ensure that they understand customers in order to assist them." A provider relations representative resume example shows how listening skills is used in the workplace: "communicated with providers about best practices in improving the tricare member experience and resolved claim issues to maintain positive relationships. "
Patience. provider relations 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 relations representatives do with patience on a typical day: "maintain a high level of professionalism, patience and efficiency to maximize customer satisfaction and increase customer loyalty and retention. "
Problem-solving skills. Another crucial skill for a provider relations representative to carry out their responsibilities is "problem-solving skills." A big part of what provider relations representatives relies on this skill, since "representatives must determine solutions to customers’ problems." How this skill relates to provider relations representative duties can be seen in an example from a provider relations representative resume snippet: "resolved problems concerning claims, capitation, appeals, fee schedules, and provider/member complaints. "
Communication skills. While "communication skills" is last on this skills list, don't underestimate its importance to provider relations representative responsibilities. Much of what a provider relations representative does relies on this skill, seeing as "customer service representatives must be able to provide clear information in writing, by phone, or in person." Here is a resume example of how this skill is used in the everyday duties of provider relations representatives: "maintain regular communications regarding claims issues and needs with client. "
The three companies that hire the most provider relations representatives are:
- IIntermountain Healthcare52 provider relations representatives jobs
- UUnitedHealth Group11 provider relations representatives jobs
- TTarzana Treatment Centers7 provider relations representatives jobs
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Compare different provider relations representatives
Provider relations representative vs. Technical service representative
A Technical Service Representative is responsible for providing customer service with customers' technical and network issues. They perform troubleshooting procedures through remote communication to fix end-users' problems on their hardware and software systems.They diagnose the system failures according to the customers' descriptions and identify technical solutions to avoid the reoccurrence of the same problem. A Technical Service Representative must have excellent communication and technical skills to navigate systems and ensure that the customers receive the highest satisfaction.
There are some key differences in the responsibilities of each position. For example, provider relations representative responsibilities require skills like "customer service," "provider relations," "medicaid," and "patients." Meanwhile a typical technical service representative has skills in areas such as "customer satisfaction," "switches," "lan," and "vpn." This difference in skills reveals the differences in what each career does.
Technical service representatives earn the highest salaries when working in the technology industry, with an average yearly salary of $44,903. On the other hand, provider relations representatives are paid more in the health care industry with an average salary of $40,474.The education levels that technical service representatives earn slightly differ from provider relations representatives. In particular, technical service representatives are 5.0% less likely to graduate with a Master's Degree than a provider relations representative. Additionally, they're 0.3% more likely to earn a Doctoral Degree.Provider relations representative vs. Representative
Representatives are lawmakers who represent the people in a specific district. They run for office to represent their districts in their hometown or their current place of living. Representatives are usually charismatic and good communicators. These characteristics are especially important during campaign and election periods. Representatives should be able to capture the hearts of the voters through their planned projects and advocacies. They are then elected by their constituents. Upon election, representatives author bills that will eventually be passed into law should it be approved by the majority of the congress. They also vote on the passage of bills authored by other representatives. They also participate in discussions and debates regarding different bills, issues, and laws. Representatives are expected to vote according to their conscience and in consideration of the voice of their constituents.
While some skills are similar in these professions, other skills aren't so similar. For example, resumes show us that provider relations representative responsibilities requires skills like "provider relations," "health plan," "issue resolution," and "network development." But a representative might use other skills in their typical duties, such as, "cleanliness," "customer issues," "credit card," and "product knowledge."
Representatives earn a lower average salary than provider relations representatives. But representatives earn the highest pay in the transportation industry, with an average salary of $36,557. Additionally, provider relations representatives earn the highest salaries in the health care with average pay of $40,474 annually.In general, representatives achieve similar levels of education than provider relations representatives. They're 3.4% less likely to obtain a Master's Degree while being 0.3% more likely to earn a Doctoral Degree.Provider relations representative vs. Housing management representative
A housing management representative directly communicates with clients in housing services. Their responsibilities include responding to inquiries and concerns, helping clients understand the terms and extent of services, offering payment arrangements, and negotiating contracts, building positive relationships along the way. They may also participate in performing research and analysis, generating leads, gathering and analyzing housing applications, and coordinating with internal and external business partners. Moreover, as a housing management representative, it is essential to maintain an active communication line with staff for a smooth and efficient workflow.
The required skills of the two careers differ considerably. For example, provider relations representatives are more likely to have skills like "provider relations," "health plan," "issue resolution," and "network development." But a housing management representative is more likely to have skills like "logistics," "internal audit," "payment arrangements," and "iso."
Housing management representatives make a very good living in the telecommunication industry with an average annual salary of $51,811. On the other hand, provider relations representatives are paid the highest salary in the health care industry, with average annual pay of $40,474.Most housing management representatives achieve a similar degree level compared to provider relations representatives. For example, they're 2.1% less likely to graduate with a Master's Degree, and 0.5% less likely to earn a Doctoral Degree.Provider relations representative vs. Support representative
The primary job of technical support representatives is to answer incoming calls and resolve customer problems or complaints related to computer hardware and software. They typically work in team environments and report directly to the technical department manager. Aside from answering phone calls, they also maintain the solutions database and respond to online chat requests and technical support emails. A successful technical support representative should have an in-depth knowledge of diagnosing and fixing computer problems, customer service skills, and problem-solving skills.
Types of provider relations representative
Updated January 8, 2025
