Provider Relations Specialist

Provider Relations Specialist

$49,920 - $72,800 / Per Year

Overview

The Provider Relations Specialist supports the operation of Elderwood IPA's provider network by maintaining provider relationships and coordinating provider onboarding, orientation, credentialing and recredentialing, contracting documentation, provider data maintenance, compliance tracking, provider education, and issue resolution. The Provider Relations Specialist serves as a liaison among providers, Elderwood IPA departments, and contracted partners to support delegated functions and other provider network initiatives.

Responsibilities

Supports provider recruitment and network development activities based on identified organizational and network needs.

Develops and maintains positive working relationships with providers participating in EIPA's network and providers supported through contracted programs.

Serves as a contact for providers and acts as a liaison between providers and EIPA.

Coordinates provider credentialing and recredentialing activities, including review of applications and supporting documentation for completeness.

Follows up with providers and appropriate office staff regarding missing, incomplete, or expired credentialing and compliance information.

Tracks required provider documentation, including licenses, insurance, accreditation, ownership information, and other requirements applicable to the provider type.

Coordinates primary-source verification through EIPA's designated credentialing verification vendor, reviews returned information for completeness and escalates discrepancies or adverse findings for formal review.

Maintains complete and accurate provider credentialing and recredentialing records.

Monitors credentialing, recredentialing, contract, insurance, and other provider compliance deadlines and follows up to support timely completion.

Coordinates provider intake and onboarding from initial request through activation, including collection and review of applications, agreements, rosters, demographic information, and supporting documents.

Maintains complete and timely Provider Contact Logs and other required documentation in designated systems.

Processes provider complaints and coordinates documentation, follow-up, communication, and closure in accordance with established procedures.

Supports quality concern and corrective action workflows and escalates clinical, compliance, legal, or contractual concerns to the appropriate owner.

Supports provider terminations, service closures, ownership changes, and other network changes by coordinating notices, documentation, system updates, and internal follow-up after required decisions and approvals are made.

Supports the provider contracting process by distributing approved agreements and amendments, collecting required documentation, tracking signatures and approvals, and maintaining executed contract records. Escalates requested changes to contract terms, reimbursement, or other material provisions for management review.

Maintains accurate provider and practitioner demographic, service, contract, credentialing, and roster information in designated systems and updates records when changes are received.

Conducts provider orientations and ongoing provider education, including developing and updating orientation materials and instructions.

Communicates approved policies, procedures, payer requirements, and operational updates to providers, including requirements related to referrals, authorizations, documentation, billing, and claims submission.

Researches provider claim issues by gathering claim details and supporting documentation, coordinating review with the appropriate internal department or payer contact, and communicating status and outcomes to the provider.

Receives and responds to incoming Provider Relations calls and other external provider-related issues.

Maintains current knowledge of EIPA's delegated functions, provider requirements, contracted programs, payer requirements, and applicable departmental procedures.

Travels as needed to providers' offices.

Provides training for other department specialists and/or coordinators as directed.

Assists with departmental projects related to EIPA's delegated functions and provider network responsibilities.

Participates in departmental and cross-functional meetings and collaborates with Clinical Operations, Quality, Compliance, Claims, Finance, Information Technology, Legal, and payer contacts as needed.

Complies with organizational policies and procedures related to timekeeping, attendance, dress and identification, and use of electronic devices.

Supports EIPA's Mission, Vision, and Values and complies with its code of conduct, compliance requirements, and HIPAA policies

Performs other duties within the scope of the position as assigned by the Provider Relations Manager or management.

Qualifications

Minimum of an associate degree; bachelor's degree preferred.

Minimum of three (3) years of experience in a managed care setting, medical office or facility setting with demonstration of medical administration duties.

Working knowledge of provider contracting, credentialing, and healthcare administrative processes.

Current, valid driver's license.

Demonstrates computer skills, including Microsoft Office, email, electronic recordkeeping systems, and web-based applications.

Prior experience in managed care, provider relations, credentialing, contracting, claims research, or healthcare administration preferred

Clear and professional telephone, written, virtual, and in-person communication skills, interpersonal effectiveness, and cultural sensitivity.

Ability to review administrative and technical information, identify missing information or discrepancies, and coordinate appropriate next steps.

Excellent attention to detail and organizational skills, with the ability to manage multiple priorities, deadlines, follow-up items, and provider records.

Sound judgment regarding when to resolve an issue independently and when to escalate it.

Ability to handle sensitive, confidential information and maintain privacy.

Ability to work independently and collaborate effectively across departments.

Intermediate proficiency with Microsoft Excel, including sorting, filtering, maintaining spreadsheets, and reviewing data for accuracy.

Working proficiency with Salesforce or a comparable customer relationship management system preferred, with the ability to demonstrate proficiency within 90 days of hire.

This position requires regular interaction with residents, coworkers, visitors, and/or supervisors. In order to ensure a safe work environment for residents, coworkers, visitors, and supervisors, this position requires that the employee be able to read, write, speak, and understand the English language at an intermediate or more advanced level.

EOE Statement

WE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to mental or physical disability, race, color, religion, gender, national origin, age, genetic information, military or veteran status, sexual orientation, marital status or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.