Internal Provider Relations Representative
Senior Whole Health 8 reviews - Massachusetts

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Position Summary:
The Internal Provider Relations Representative is responsible for assisting and servicing all medical services, SNF, ancillary, and community based providers in the SWH network as well as managing and supporting relationships with certain providers. These responsibilities include: telephonically monitoring, managing and resolving operational and/or contractual issues, contributing to the efforts of the PR/ND team in servicing and expansion activities; and acting as a dedicated resource and knowledge center for the provider call line and PR mailbox.

Essential Functions/Responsibilities:
Work with internal and external PR and cross-departmental SWH staff to resolve specific provider issues with regard to billing, payments, denials, authorizations, fee schedule set up and other interactions; assist in the development and implementation of organizational solutions to prevent future issues.
Research and assist in resolution of internal process issues involving but not limited to the following departments: Claims, Provider Operations, Enrollment, Clinical, Member Services, IT, etc.
Prepare analysis of claims and payment trends.
Train and educate providers, with occasional external visits as needed.
Conduct analysis to support contracting process.
Function as designated PR rep for certain unassigned providers, including SNF, ancillary and community based providers.
Work with key provider accounts undergoing significant changes (e.g. TIN, name/address, overall cleanups, panel status, other demographic changes) by managing interface with Provider Operations.
Prepare standard monthly provider reports and develop other adhoc reports as needed.
Identify issues and inconsistencies in provider database and work with IT to address.
Follow up with providers regarding confirmation of changes, and maintaining appropriate documentation, submit and track Provider Update forms as needed.
As needed, support PR external staff in the resolution of provider issues.
Function as designated responder for provider relations call line – respond to calls on eligibility, authorization and benefits questions, claims questions and work on resolution of more complex/involved issues in collaboration with the designated representative.
Manage all internal provider based inquiries/issues; triage inquiries, facilitate resolution of incoming requests and/or forward such requests as appropriate.
Maintain current knowledge of updated SWH policies/procedures.
Manage and/or support other projects and activities as assigned.
Provide excellent level of customer service.

Bachelor’s degree preferred.
Working knowledge of healthcare reimbursement methodologies.
Working knowledge of and experience with Medicare and Medicaid programs.
At least 4 years experience working in a health care environment, preferably in the managed care industry.
At least 2-3 years experience working in Provider Relations or provider-based environment.
At least 2-3 years experience with claims resolution and familiarity with credentialing processes.
Excellent Microsoft skills; database skills desirable.
Network of relationships with local providers, including SNF, medical services, and community based services highly desirable.


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8 reviews