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Provider Relations Representative Resume Example

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Jessica Claire
, , 100 Montgomery St. 10th Floor
Home: (555) 432-1000 - Cell: - resumesample@example.com - -
Professional Summary

Jessica Claire PROFILE: Accomplished Provider Relations Representative with over 16+ year of experience specializing in delivering exceptional education, support, and customer service to healthcare providers throughout the state of Arizona. Understanding the dynamics and regulations for multiple payer types including Commercial, Medicare, and Medicaid. Strong analytical and problem-solving abilities while connecting with assigned healthcare providers' needs to create a memorable experience.

Skills
  • Caring and Empathetic
  • Administrative and Office Support
  • Verbal and Written Communication
  • Resolving Problems
Work History
05/2017 to Current
Provider Relations Representative Common Spirit Corbin, KY,
  • Serve as a liaison between the health plan and contracted network providers to provide orientation training, ongoing education, and research/resolve complex claims issues within the Phoenix metropolitan county.
  • Field work – local travel 3 days weekly, spent primarily with administrative customer service support.
  • Managing monthly communications and face to face provider visits and calendar events.
  • Perform financial analysis and participate in market financial review with senior management.
  • Facilitate and participate in provider education fairs, webinars, monthly meeting, and provider in-services with contracted physicians and ancillary groups via face to face, written correspondence, and telephone contacts.
  • Develop and foster strong relationships with external/internal customers.
  • Respond, research, and resolve provider complaints within a timely manner.
  • Investigate customer grievances within network.
  • Develop workgroup programs that will continue the success and goals of the Provider Relations Department.
  • Interface proactively with all health plan departments.
  • Assist with special projects and additional duties as assigned that are consistent with the company and departmental goals.
12/2008 to 02/2015
Provider Relations Representative Common Spirit El Dorado Hills, CA,
  • Serve as a liaison between the health plan and contracted network providers to provide orientation training, ongoing education, and research/resolve complex claims issues within the counties of La Paz, Mohave, Maricopa, and Pinal counties.
  • Recruit providers and perform analysis of the network via Letters of Intent (LOI) received from interested community providers.
  • Negotiate Tier 1 and 2 contracts, letters of agreements, and amendments while ensuring budget guidelines and ongoing CMS and Medicaid requirements are met.
  • Facilitate and participate in provider education fairs, webinars, monthly joint operations committee (JOCs), and provider in-services with contracted physicians, hospitals, and ancillary groups via face to face, written correspondence, and telephone contacts.
  • Develop and foster strong relationships with external/internal clients.
  • Respond, research, and resolve provider complaints within a timely manner.
  • Create, write, and maintain desktop procedures.
  • Lead and develop workgroup programs that will continue the success and goals of the Provider Relations Department.
  • Interface proactively with all health plan departments.
  • Assist with special projects and additional duties as assigned that are consistent with the company and departmental goals.
09/1999 to 08/2007
Enrollment Specialist Alliant Houston, TX,
  • Entered enrollment and disenrollment products for Secure Horizons in Arizona and Nevada regions.
  • Initiated, maintained, and developed accurate membership records for Arizona and Nevada regions using internal systems including Iliad, McCoy, Acxiom, MAS database, and RX Solutions.
  • Educated enrollees, internal/external customers regarding enrollment and disenrollment policies and procedures utilizing established company procedures/Federal guidelines.
  • Maintained confidentiality of membership information, by accessing secured data systems and following HIPAA policies and procedures.
  • Worked discrepancy and statistic report.
  • Responsible for maintaining data integrity for statistic, revenues, and database entries.
  • Preparation for Sales Representative's presentation and brochure packets.
  • Processed Medical Record Release of Information requested from patients.
  • Understood and thoroughly explained services provided to customers and potential customers.
Education
Expected in
Associate of Applied Science: Business Management
Jefferson Technical College - Steubenville,OH,
GPA:
Expected in
High School Diploma:
Wintersville High School - Wintersville, OH,
GPA:
Accomplishments
  • Centers for Medicare and Medicaid Services (CMS) and Arizona Health Care Cost Containment System (AHCCCS) Regulation Payer Key
  • Achieved average of 95% provider satisfaction rating for 5 consecutive years.
  • Helped Banner Health achieve 1st Place in AHCCCS Provider Survey in 2015.
Affiliations
  • Secured 10 key contracts in the 2014 CMS Bid
  • Serve as a member of HIPAA & Compliance Committee
  • Serve as a member of the Service Excellence Committee
  • Volunteer to Community in Immunity for COVID-19

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Resume Strength

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  • Personalization
  • Strong Summary
  • Target Job

Resume Overview

School Attended
  • Jefferson Technical College
  • Wintersville High School
Job Titles Held:
  • Provider Relations Representative
  • Provider Relations Representative
  • Enrollment Specialist
Degrees
  • Associate of Applied Science
  • High School Diploma