Provider Relations Representative

Provider Relations Representative

The Provider Relations Representative serves as a key liaison between CareFirst and its provider network, supporting healthcare providers through proactive communication, issue resolution, and relationship management. This role focuses on ensuring providers receive accurate, timely assistance with claims, credentialing, setup, and operational concerns. The ideal candidate will bring a strong understanding of healthcare billing, claims processes, and Medicare/Medicaid programs, combined with excellent communication and organizational skills.

The Provider Relations Representative will:

• Act as the primary point of contact for provider inquiries, ensuring timely and professional resolution.
• Manage and respond to 25–45 calls and emails per day related to provider questions, concerns, or escalations.
• Triage and resolve issues involving claims, provider setup, credentialing, and general service needs.
• Support internal departments in addressing provider concerns when no assigned representative is available.
• Collaborate with cross-functional teams to streamline issue resolution and enhance provider satisfaction.
• Maintain detailed documentation of all interactions and resolutions within CareFirst systems.
• Assist with small-scale project management activities tied to provider operations and performance initiatives.
• Contribute to the continuous improvement of provider service processes through feedback and trend analysis.

Required Skills:

• 3+ years of hands-on experience working with healthcare claims (submitting, filing, or resolving).
• Strong understanding of Medicare and Medicaid billing and reimbursement.
• Experience in provider relations, provider services, or billing within a payer or provider environment.
• Proficiency in Microsoft Excel — must be able to filter, sort, and create pivot tables.
• Excellent communication skills (10/10 verbal and written) — ability to communicate clearly with providers and internal stakeholders.
• Ability to manage multiple priorities in a high-volume, fast-paced environment.

Preferred Qualifications:

• Experience using Facets, FEP Direct, GuidingCare, CareFirst Direct, or NASCO systems.
• Knowledge of CareFirst PPO Plans, Blue Choice HMO, Blue Card, Medicare Advantage, and Medicaid programs.
• Certified Professional Coder (CPC) or related credential.
• Prior experience with CareFirst systems or provider network operations.

Lumen Solutions Group Inc. is an Equal Opportunity Employer and does not discriminate in employment on the basis of Minority/Gender/Disability/Religion/LGBTQI/Age/Veterans.