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provider relations representative resume example with 18+ years of experience

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

Enthusiastic Central Baggage Resolution Specialist eager to contribute to team success through hard work, attention to detail and excellent organizational skills. Clear understanding of collaborating and workforce and training in company's system. Motivated to learn, grow and excel in airline industry. To seek and maintain a full-time position that offers professional challenges utilizing interpersonal skills, excellent time management and problem-solving skills.

Skills
    • Organized and Efficient
    • Time Management and Prioritization
    • Service optimization
    • Workflow Analysis
    • Data analysis
    • Customer Relations
    • Good communication skills
    • Telephone etiquette
    • Professional telephone demeanor
    • Quality assurance
    • Creative problem solving
    • Service standard compliance
    • Administrative support
    • Excellent written and oral communication
Work History
05/2017 to 10/2021 Provider Relations Representative Common Spirit | Northridge, CA,
    • Conducted 18 field visits with community health centers to provide outreach and resolutions to provider inquires.
    • Educated providers about provider manuals, directories, and outline provider resource tools.
    • Processed medical provider network applications with 90% level of accuracy.
    • Collaborated with providers to develop optimum health care delivery, resolve issues, and provide continued support.
    • Researched and resolved provider issues regarding reported complaints and claims.
    • Maintained contract requirements by completing appropriate forms and obtaining attendance logs for visits.
    • Maintained accurate and current provider database relating to provider facilities and physician information.
    • Analyzed, monitored, and modified provider contracts to appropriate fee schedules.
    • Utilized internal software to generate reports to support credentialing, contract negotiating, and provider services activities.
    • Resolved issues that could affect care progression by ensuring flow of information and solving problems.
    • Identified insurance payer sources and verified insurance coverage.
    • Attending on-going training and professional development course to become aware of new developments in healthcare.
    • Investigated patient inquires thoroughly to achieve satisfactory resolution.
12/2008 to 02/2015 Provider Relations Representative Common Spirit | Centerville, IA,
    • Service as liaison between health plan and contracted network providers to provide orientation training, ongoing education, and research/resolve complex claim issues within counties of La Paz, Mohave, Maricopa, and Pinal for state of Arizona.
    • Recruit providers and perform analysis of network via Letter of Intent (LOI) received from interested community providers.
    • Negotiate Tier 1 and 2 contracts, Letter of Agreement (LOA), amendments while ensuring budget guidelines and ongoing Centers Medicare and Medicaid Services (CMS) requirements are met.
    • Facilitate and participate in providers education fairs, webinars, monthly Joint Operations Committee (JOC), and provider in-services with contracted physicians, hospitals, ancillary groups via face to face, written correspondence, and telephone contacts.
    • Develop and foster strong relationship with external/internal clients.
    • Create, write, and maintain desktop procedures.
    • Lead and develop workgroup programs that will continue success and goals for Provider Relations Network.
    • Interface proactively with all health plan departments.
    • Assist with special projects and additional duties as assigned that are consistent with company and department goals.
    • Managed provider relations mailbox by triaging inquiries, facilitating resolution of incoming requests and forwarding requests to appropriate parties
09/1999 to 08/2007 Enrollment Specialist All Service Financial | Fort Lauderdale, FL,
    • Initiated, maintained, and developed accurate memberships records for Arizona and Nevada regions using internal system (Iliad, McCoy, Axiom, MAS database, and RX Solutions).
    • Screened senior, aging, and disabled populations for service eligibility.
    • Verified and completed enrollment/disenrollment applications for Medicare and Medicaid for Arizona and Nevada regions.
    • Educated members, internal, external customers regarding enrollment/disenrollment policies and procedures utilizing company's procedures and CMS guidelines.
    • Interacted professionally with providers and ancillary staff to coordinate resolutions for diverse problems.
    • Promoted plans by skillfully explaining features and advantages and turning objections around to complete sales.
    • Responsible for maintaining data integrity for statistic, revenues, and database entries.
    • Preparation brochures packets and presentation for Sales Representatives.
    • Met and exceeded revenue goals by 85% through generating new leads and identifying new clients
Education
Expected in 12/1986 to to Associate of Science | Business Management Jefferson Technical College, Steubenville, OH, GPA:
Expected in 06/1983 to to High School Diploma | Indian Creek High School, Wintersville, OH GPA:
Affiliations
  • HIPAA and Compliance Committee
  • Service Excellence Committee
  • Volunteered Community in Immunity for COVID 19


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Resume Overview

School Attended

  • Jefferson Technical College
  • Indian Creek High School

Job Titles Held:

  • Provider Relations Representative
  • Provider Relations Representative
  • Enrollment Specialist

Degrees

  • Associate of Science
  • High School Diploma

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