Provider Relations Representative

The Provider Relations Representative evaluates assigned territories and is responsible for recruiting, contracting, and maintaining relationships with physicians, specialists, ancillary providers, and hospitals to support a high-quality, cost-effective provider network.
Key Responsibilities:

- Identify and target potential providers to establish contractual agreements aligned with network needs.

- Analyze and evaluate assigned territories to determine provider recruitment gaps and opportunities.

- Recruit and contract physicians, specialists, ancillary providers, and hospitals, ensuring completion of all required documentation, including credentials and site visits.

- Conduct site visits for all newly contracted providers to verify compliance with network and regulatory standards.

- Negotiate provider contracts and reimbursement rates using utilization and claims data to support financially sound agreements.

- Serve as a primary point of contact for provider inquiries related to contracts, network participation, and Health Network One operations.

- Collaborate with contracted providers to integrate services into the overall care delivery network.

- Maintain effective communication with internal departments and participating providers to support network development and provider referrals.

- Support the Credentialing Department by assisting with the collection and maintenance of credentialing and re-credentialing documentation.

- Maintain accurate and up-to-date provider files and ensure data integrity in company systems and databases.

- Analyze claims and utilization data for newly contracted providers to evaluate performance and contract profitability.

- Prepare reports and summaries for presentation to senior management.

- Ensure compliance with HIPAA regulations and all company policies and procedures.

- Perform additional related duties as assigned.

Required Qualifications:

- Associate’s degree or equivalent from an accredited two-year college or technical school, or an equivalent combination of education and experience.

- Two to three years of experience in a physician office, HMO, managed care organization, or other healthcare environment.

Preferred Qualifications:

- Experience in provider contracting, network management, or managed care operations.

- Familiarity with claims analysis, utilization data, and provider reimbursement structures.

Location/Travel:
- Remote, may require travel within territory based on network needs

Originally posted on Himalayas