Internal Provider Relations Representative (Eng/Spa Required)

Interacts with and discusses contract and credentialing with physicians, specialist, ancillary providers and hospitals. Performs revenue analyses for the Provider Relation/ Network Department.

Essential Functions & Responsibilities

• Target and/or follow-up with potential providers to establish contractual agreements.
• Interacts with provides regarding all contract matters for HN1 including any necessary documentation. (i.e. credentialing, applications, W-9, PIP, etc)
• Recruits and contracts physicians, specialists, ancillary providers and hospitals for HN1.
• Responds to provider inquiries regarding contract matters, provider networks issues and HN1 operations.
• Works with contracted providers to help integrate their services into the overall care delivery network.
• Researches and solves any questions or concerns that providers, external provider representatives, Health Plans and other internal departments, may have
• Analyzes, prepares, maintains and distributes various departmental reports, including specialized reports for providers or networks; HN1 quarterly provider bulletins; various presentations and custom reports requested by Senior Management.
• Organize, develop and execute provider outreach projects.
• Researches provider’s utilization data with reference to negotiating new rates and utilization performance of individual providers and the network.
• Maintain lines of communications with all internal departments and with all participating providers in enlisting their assistance in referring potential providers in the Network.
• Attend corporate and departmental meetings to assist with company projects and goals (i.e.
• URAC, Executive Committee meetings, etc.)
• Ensures compliance with and/or adheres to company HIPAA policies and procedures.
• Ensures integrity of data entered into company systems and databases.
• Manage the normal office activities for the Network Department to include but not limited to:
• Maintains and updates physician files.
• Composes and types routine correspondences
• Reads and routes incoming mail and prepares outgoing mail and correspondences, including emails and faxes.
• Answers and screens departmental telephone calls, and arranges conference calls.
• Coordinates department’s schedule and schedules appointments
• Arranges and coordinates travel schedules and reservations
• Coordinates and arranges meetings, prepares agendas, reserves and prepares facilities, and records and transcribes minutes of meetings.
• Other Responsibilities
• Support other departments as needed.
• Supports Credentialing Department by assisting with the collection of physician credentials for re-credentialing purposes.
• Evaluates claim data on recently contracted providers, ensuring contract is profitable for Company.