Provider Relations Specialist-- Western Massachusetts

Job Description

Job Description

Description:

Title: Provider Relations Specialist

Job Type: Full-time

Region: Western Massachusetts

Location: Field based, 1 day per week in Brighton, MA office

FLSA Status: Exempt

Position Summary

The Provider Relations Specialist supports the Provider Relations team in managing all provider relations requirements for the US Family Health Plan (USFHP) of Southern New England provider network. This role serves as a contracting and educational liaison between the Plan and its providers, ensuring compliance with Plan policies, TRICARE requirements, and contractual obligations. The Specialist is responsible for network engagement, provider onboarding, and issue resolution, while collaborating with internal teams to advance organizational goals and enhance member and provider experience.

Key Responsibilities

Provider Network Engagement & Education

• Serve as the primary point of contact for contracted providers, office staff, and key stakeholders.
• Conduct new provider orientation sessions and ongoing provider trainings.
• Promote positive provider relationships through proactive outreach, communication, and site visits.

Contracting & Credentialing

• Identify and support the contracting of new providers consistent with Plan objectives.
• Negotiate terms within established parameters; prepare and execute contract documents.
• Collaborate with the third-party administrator to oversee credentialing and ensure providers remain in good standing.
• Maintain accurate provider listings, databases, and contract status records.

Issue Resolution & Compliance

• Investigate, resolve, and document provider inquiries related to credentialing, contracts, claims, reimbursement, and member eligibility.
• Monitor network adequacy, access, and performance through site visits, data analytics, and provider feedback.
• Partner with Quality Management on HEDIS and quality improvement initiatives.
• Ensure compliance with TRICARE requirements and Plan policies.

Collaboration & Reporting

• Collaborate with Marketing, Sales, Care Coordination, and Quality teams on outreach, education, and provider communications.
• Track, trend, and report provider inquiries and issues to management.
• Prepare analytical reports on network status, including gaps and performance improvement opportunities.
• Participate in special projects, events, and initiatives in support of Plan goals.
• Other duties as assigned.

Qualifications

Education and Experience

• Bachelor’s Degree required.
• 2–5 years of provider relations, contracting, credentialing, or health insurance operations experience.
• Experience in healthcare or military-related environment preferred.

Skills & Competencies

• Proficiency in Microsoft Office and CRM systems (Salesforce).
• Strong organizational, presentation, and communication skills.
• Ability to analyze data, prepare reports, and manage multiple priorities under deadlines.
• Knowledge of medical and managed care terminology.

Other Requirements

• Valid Driver’s License, clean driving record, and access to personal vehicle; ability to travel to provider offices.
• Ability to obtain U.S. Government personnel security clearance.
• Ability to lift up to 20 pounds.

Physical Nature of the Job

Some elements of the job are sedentary, but the employee will be required to stand for periods of time or move throughout the campus.

Equal Opportunity Employer Statement

Brighton Marine is an Equal Opportunity Employer. We prohibit discrimination and harassment of any kind based on race, color, religion, sex (including pregnancy, gender identity, and sexual orientation), national origin, age, disability, genetic information, protected veteran status, or any other characteristic protected by federal, state, or local law. We strongly encourage applications from veterans and individuals with disabilities. Accommodations are available upon request for candidates taking part in all aspects of the selection process.

Work Authorization

Candidates must be authorized to work in the United States without sponsorship now or in the future.