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.

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Required Education and Experience

English/Spanish Required

High School graduate or equivalent (GED); and previous health care experience.

Certificates, Licenses, Registrations

N/A

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