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