Provider Representative Resume Sample

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Bart Orn
17620 Cole Court,  Boston, MA
+1 (555) 759 9172

Work Experience


Senior Provider Reimbursement Representative
12/2015 - PRESENT
New York, NY
  • Two (2) to three (3) years of experience in a provider enrollment or credentials position
  • Problem solve, make decisions, and effectively communicate decisions
  • Verifying correct enrollment numbers and mailing completed agreements to the proper payer/vendor for approval
  • Following up with clients, payers and vendors to insure receipt of forms and approval by payers/vendors prior to submission by client
  • Entering all required information and approvals into the TPS and Enroll Link system for new providers, products and services to new sites
  • Answering all incoming calls to the Provider Enrollment Department
  • Working pre-billing and production reports associated with new providers, products and services
  • Manage/Update Cactus insurance plan data in the Multi-Entity Cactus Database, applying expert knowledge & experience, to ensure an accurate transfer of key data from Cactus to the MIChart – SER database
Provider Enrollment Representative
06/2011 - 11/2015
Boston, MA
  • Tracks and generates applications within 60 days of contract start
  • Conducts payer research on the provider
  • Adds providers to the group in Teamworks
  • Generates and prepares applications to send to provider
  • Generates “Application Sent to Provider But Not Returned” reports in Teamworks to follow up with providers for status of outstanding billing paperwork
  • Reviews returned packets for accuracy
  • Follows up with providers for unreturned billing paperwork
Provider Data Entry Representative
09/2007 - 04/2011
Dallas, TX
  • Analyze and evaluate network coverage to identify network needs
  • Review contracts and proposals to determine proper reimbursement
  • Negotiate fees and create contracts
  • Obtain information from providers to begin the credentialing process
  • Identify and make updates and corrections to demographics as they are identified or as received from the provider
  • Assists with preparing and updating applications for issuance of provider numbers for physicians and midlevel aka APC’s providers, makes copies, and faxes information as assigned
  • Maintenance of all provider records within the health plan system(s). Includes: setup of demographic and specialty information, panel information (if applicable), line of business and fee schedule as instructed
  • Receives notifications from the Clinician Onboarding Liaison (COL)

Education


Trinity University
2002 - 2006
Bachelor's Degree in Business

Professional Skills


  • Proven oral communication skills including telephone etiquette
  • Excellent communication skills (verbal, written, and listening)
  • Strong Interpersonal Skills; ability or desire to learn how to run small group meetings
  • Strong business, written and oral communication skills
  • Investigative, decision-making, problem-solving, interpersonal, and organization skills required
  • Prior demonstrated success in provider contracting with large physician groups
  • Expert MS Office Skills, including MS Access

How to write Provider Representative Resume

Provider Representative role is responsible for software, general, finance, training, database, auditing, reporting, research, insurance, travel.
To write great resume for provider representative job, your resume must include:

  • Your contact information
  • Work experience
  • Education
  • Skill listing

Contact Information For Provider Representative Resume

The section contact information is important in your provider representative resume. The recruiter has to be able to contact you ASAP if they like to offer you the job. This is why you need to provide your:

  • First and last name
  • Email
  • Telephone number

Work Experience in Your Provider Representative Resume

The section work experience is an essential part of your provider representative resume. It’s the one thing the recruiter really cares about and pays the most attention to.
This section, however, is not just a list of your previous provider representative responsibilities. It's meant to present you as a wholesome candidate by showcasing your relevant accomplishments and should be tailored specifically to the particular provider representative position you're applying to. The work experience section should be the detailed summary of your latest 3 or 4 positions. Representative Provider Representative resume experience can include:

  • Experience - 2 or more years business experience in a managed care or healthcare setting is required
  • Working knowledge in Long-Term Acute Care, home health, home infusion, behavioral health, ambulatory surgery, and the outpatient experience
  • Experience with claims, coding, and / or billing
  • Strong knowledge of the Billing and Reimbursement Process and its impact on reducing patient anxiety time and the Remittance Application process
  • Good judgment and intelligent reasoning including ability to deal with complex topics
  • Generate correct payer paperwork for revalidations/begin re-credentialing process

Education on a Provider Representative Resume

Make sure to make education a priority on your provider representative resume. If you’ve been working for a few years and have a few solid positions to show, put your education after your provider representative experience. For example, if you have a Ph.D in Neuroscience and a Master's in the same sphere, just list your Ph.D. Besides the doctorate, Master’s degrees go next, followed by Bachelor’s and finally, Associate’s degree.

Additional details to include:

  • School you graduated from
  • Major/ minor
  • Year of graduation
  • Location of school
These are the four additional pieces of information you should mention when listing your education on your resume.

Professional Skills in Provider Representative Resume

When listing skills on your provider representative resume, remember always to be honest about your level of ability. Include the Skills section after experience. Present the most important skills in your resume, there's a list of typical provider representative skills:

  • Facilitate Provider education, training in order to increase their familiarity and satisfaction with CarePlus Health Plans’ systems, initiatives, processes and strategies
  • Experience working in a physician’s office or sales experience
  • General computer skills including use of Microsoft Office products or equivalent software and ability to learn corporate software programs
  • Experience with claim processes experience
  • Experience with processing adjustments using UMR CPS (Claims Processing Systems)
  • Managed care or medical insurance experience, specifically in credentialing providers, working in provider relations, medical billing or quality management

List of Typical Experience For a Provider Representative Resume

1

Experience For Provider Enrollment Representative Resume

  • Experience in claims research, analysis and reporting and/or financial analysis and reporting
  • Travel covering Central Florida (Orange, Osceola, Seminole, Sumter, Marion, and Lake counties), valid driver’s license and vehicle are required
  • Travel covering Broward county, valid driver’s license and vehicle are required
  • Experience working with reimbursement methodologies
  • Requesting IDX# from billing center/IDX maintenance
  • Completing online applications/CAQH
  • Documenting data in TeamWorks
  • Resolving application deficiencies
  • Complete all maintenance activities including research, recording, communication & information sharing, submission, confirmation and follow up
2

Experience For Provider Reimbursement Representative Resume

  • Multi - tasking and applying attention to detail
  • Works to facilitate resolutions to member billing inquiries or other billing/claims issues
  • Provide data reporting on reimbursement issues with the ability to communicate findings to Leadership and Operational Teams
  • Assists company affiliates with initial deployment and ongoing support of systems and processes to leverage national network rates and policies
  • Work OT during peak periods
  • Utilize complex database systems and claims platforms simultaneously including, but not limited to NMDB, NDB, various work management applications
3

Experience For Provider Installation Representative Resume

  • Follows up on outstanding inquiries and works with special support and supervisory staff to resolve any non-compliant issues
  • Sends updated credentials to the payer
  • Primary point of contact for withdrawals; receive and update Teamworks and notify others, if needed
  • Partner with COL and Credentials Data Coordinators
  • Validation and maintenance of all provider records within the health plan system(s). Includes: validation of demographic and specialty information on an annual, semi-annual or quarterly basis
  • Responsible for data collection of reimbursement information from Third Party Payers, accountable for completeness and integrity of data
  • Conduct routine audits of Third Party Payers to discern the root cause of Fee Schedule Reimbursement differences, Denial concerns, and identifying Pricing issues related to reimbursement rates
  • Generate ad - hoc reports for leadership and analytical staff for special projects and routine analysis
4

Experience For Provider Contracting Representative Resume

  • Develops programs, policies and strategies to ensure that contracted rates and reimbursement policies are applied accurately for company affiliates
  • Analyzes claims, pre and post payment, to ensure contracts and reimbursement policies and procedures are priced accurately
  • Reviews claim disputes to verify correct pricing and analyzes claim inquiry data to determine root cause of errors; recommends system changes, training and process improvements to prevent future errors
  • Works with both internal and external customers to identify and resolve complex problems
  • Fee schedule and contract template maintenance is also included in this function
  • Provide data reporting on reimbursement issues with the ability to communicate findings at a National Level, Centralized and Decentralized, to members of the Leadership and Operational Teams
  • Maintain Analysis Sheet of all findings and tracking to the completion of data collection on Reimbursement projects and provide status reports
5

Experience For Provider Engagement Representative Resume

  • Manipulate MS Excel and Access to extract data from different sources
  • Work closely with all levels of staff at the NRSC and Business Units, both Centralized and Decentralized, on projects identifying and capturing Reimbursement Opportunities
  • Generate ad-hoc reports supporting all levels for leadership and analytical staff for special projects and routine analysis
  • Conduct outbound calls or Web Research to collect data from both internal and external customers, including but not limited to Health Plans Operations Team, Sales Managed Care Team, Medical Coding and Compliance Team, Centralized and Decentralized BU National, Regional and Government Analysts, BSRs, as well as to our Third Party Payers and Clients
  • Enters the provider data once the data is validated for accuracy so that providers are paid correctly from the beginning of their affiliation with the Plan
  • Independently initiates oversight of existing provider record problems
  • Coordinates set up and hand off of provider records to Credentialing Department
  • Responsible for accurate set up of provider records in order to assure proper payment for providers
6

Experience For Provider Data Attestation Representative Resume

  • Handles all implementation steps to enroll providers in the Plan to ensure timely access for members and accurate payment for providers
  • Manages the interaction with providers and office managers to ensure that all necessary information is collected and analyzed so providers can be credentialed and loaded in the system accurately according to department standards
  • Acquires and demonstrates a thorough knowledge of the unique arrangements and ensures the Plan enrolls providers with those arrangements
  • Identifies system problems with provider set up and facilitates resolution so that provider payments are accurate
  • Completes provider data input and assures data forms are completed per BMCHP requirements
  • Reviews submitted application and supporting documentation to ensure the data captured through the enrollment process is in compliance with NCQA, applicable state requirements
7

Experience For Senior Provider Reimbursement Representative Resume

  • Follows established contracting process to ensure the smooth implementation of the provider contracts. Tracks, maintains and communicates information pertaining to the status of contracts in accordance with the established contracting process
  • Researches, facilitates and assists with resolution of interdepartmental issues related to enrollment as identified by providers and internal BMCHP staff
  • Maintains the integrity of Provider Data in Onyx
  • Provides system analysis support as needed to ensure operational compliance with Plan provider and database rules
  • Develops basic reports in Onyx in order to provide and communicate information
8

Experience For Representative, Provider Services Resume

  • Direct supervision is received weekly
  • Work as a team member, to manage multiple tasks, to be flexible, and to work independently and possess excellent organizational and problem solving skills
  • Regular and reliable attendance is an essential function of the position
  • Educate providers by instructing and advising of the comprehensive policies and procedures involving all phases of the corporation’s benefits and contracts through office visits and communication over the phone and email
  • Assist in the design and implementation of programs that build / nurture positive relationships between the health plan, providers and practice managers
  • Support development and management of provider networks
  • Coordinate development between customer, network and United Medical Resources (UMR) internal departments
  • Assist with programs designed to ensure proper application of contracted rates and reimbursement policies for company affiliates
  • Act as a technical resource to others and proactively identify solutions to non-standard requests
9

Experience For Provider Data Entry Representative Resume

  • Generate "Applications Stopped in House" reports from TeamWorks
  • Work with minimal guidance; seek guidance on only the most moderately to complex tasks
  • Triage inquiries received in our group mailbox
  • Initiates, coordinates and participates in problem-solving meetings between the provider and Molina stakeholders, including senior leadership and physicians. Such meetings would occur to discuss and resolve issues related to utilization management, pharmacy, quality of care, and correct coding, for example
  • 2016 Healthiest Employers of Central Ohio recipient
  • Lives the values: Integrity, Community, Collaboration and Stewardship, as defined in the performance appraisal
  • Work with both members and providers and provide accurate information to both customer bases
10

Experience For Provider Performance Representative Resume

  • Adheres to stringent call center schedule including beginning work on time, keeps absences within guidelines, returns on time from breaks and meals, and displays flexibility when scheduling time off
  • Supports providers for network expansion
  • Initiates and facilitates contracting and credentialing of providers, including coordination with credentialing and provider contracting, as well as follow up with the provider on final outcome
  • Educates the provider community on company policy, contractual obligations, and billing guidelines for all lines of business and varying payment methodologies
  • Researches and communicates complex medical and reimbursement policy issues to the provider
  • Serves as a resource to other divisions by researching and responding to provider contracting questions, complicated claims issues and provider demographic issues
  • Supports demographic changes and system setups to ensure accuracy of claims payment
  • Promotes and trains provider office staff on the use of our Provider Web-site
  • Supports the grievance and appeals process

List of Typical Skills For a Provider Representative Resume

1

Skills For Provider Enrollment Representative Resume

  • Validate pricing data prior to submission and assist with post system load comparisons
  • Action orientation with ability to prioritize workload and focus on highest priorities
  • Communicate effectively with external parties, both verbal and written
  • Document issues and recommend solutions effectively, both verbal and written
  • Prioritize workload and focus on highest priorities
  • Demonstrates a working commitment to aiding in fulfillment with all company operating goals
  • Experience in Provider Contracting or Provider Relations in an insurance or healthcare setting
  • Use good judgment and intelligent reasoning including ability to deal with complex topics
2

Skills For Provider Reimbursement Representative Resume

  • Travel covering the Dade County, valid driver’s license and vehicle are required
  • Travel covering the Palm Beach county area, valid driver’s license and vehicle are required
  • Travel primarily covering Broward county, valid driver’s license and vehicle are required
  • Experience with claim processes, workflows, and management reporting
  • Medical billing experience
  • Customer service, provider service, or claims experience in a managed care setting
  • Researches and obtains information from providers for internal process improvement and for enhancing the provider’s experience
  • Valid State of Florida Driver’s license
3

Skills For Provider Installation Representative Resume

  • Experience in healthcare customer service
  • Demonstrated, Extensive Knowledge of the Multi-Entity Cactus Database
  • Provider Enrollment Processes experience
  • Experience healthcare customer service
  • Independently prioritize and organize own work to complete daily tasks within required business mandated time frames
  • Strong knowledge of standard PC packages (Microsoft Word, Microsoft Excel and Microsoft Outlook)
  • Experience in health care or related industry
  • In-depth understanding of medical terminology, CPT, HCPCS, ICD coding and experience related to the use of RBRVS
4

Skills For Provider Contracting Representative Resume

  • Experience with Microsoft Access (reporting and analysis)
  • Experience in a position related to managing hospital, physician, dental, and / or pharmaceutical networks that support a client base
  • Experience in claims research, analysis and reporting
  • Experience utilizing the CPS claims platform within UMR
  • Establish and maintain effective professional relationships with customers
  • Demonstrated analytical ability to identify problems, develop solutions, and implement chosen course of action
  • Experience in a claims, customer service or provider support role
5

Skills For Provider Engagement Representative Resume

  • Experience with Basic CPT / HCPC knowledge
  • Experience on Cosmos., CSP Facets and / or NDB
  • Experience performing financial statement analysis
  • Experience communicating regularly with external customer
  • Excellent proficiency with Microsoft Outlook, Word and Excel
  • Demonstrated competence using Microsoft Office products especially Word, Excel, Outlook, Access, PowerPoint
  • Experience or knowledge of ONYX, FACETS and/or similar provider data and/or claims processing system
  • Interfacing with providers to answer inquiries or gather further information regarding a provider’s enrollment via telephone and written correspondence
  • Preparing and sending applications to payers
6

Skills For Provider Data Attestation Representative Resume

  • Working knowledge of Microsoft Office applications Outlook, Word, and Excel
  • Onboarding, maintenance and administration of networks
  • Microsoft Excel proficiency (filtering, sorting, creating, and editing spreadsheets)
  • Proficiency with Access - basic quering, creating new tables, linking tables together
  • Multi-tasking and applying attention to detail
  • Substantial knowledge of medical billing policies, processing guidelines and requirements
  • Six Sigma project participation; including working knowledge of Six Sigma methodology
  • Work closely with all levels of staff within Optum360 and Quest Diagnostics on projects identifying and capturing Reimbursement Opportunities
  • Provides assistance with ongoing quality initiatives related to improved data processing and workflows
7

Skills For Senior Provider Reimbursement Representative Resume

  • Interact professionally with providers and staff representatives to provide information on any necessary documentation required for processing
  • Facilitate provider education, training them in order to increase their familiarity and satisfaction with Humana/CarePlus’s systems and strategies
  • Consistent demonstration of accuracy, thoroughness and timeliness in completing work assignments
  • Proficiency with Excel - creating formulas and pivot tables
  • Actively participates in any required training on as needed basis
  • Maintain Analysis Log of all findings and tracking to the completion of data collection on Reimbursement projects and provide status reports
  • Recognize Reimbursement improvement opportunities with emphasis on Cash Realization, Denial Reduction and improving data management techniques
  • Analyze claims, pre and post payment, to ensure proper pricing of contracts, reimbursement policies and procedures
8

Skills For Representative, Provider Services Resume

  • Review claim disputes to verify correct pricing and analyze claim inquiry data to determine root cause of errors
  • Recommend system changes, training and process improvements to prevent future errors
  • Update management when payers request additional forms or updating PE forms
  • Partner with Clinician Onboarding Liaison (COL) and Credentials Coordinator (CDR)
  • Perform analysis of claims, pre and post payment, to ensure proper pricing of contracts, reimbursement policies and procedures
9

Skills For Provider Data Entry Representative Resume

  • Assists in synchronization of data among multiple claims systems and application of business rules as they apply to each database
  • Validates the data to be housed on provider databases and ensuring adherence to business and system requirements of customers as it pertains to contracting, network management and credentialing
  • Knowledge of capitation, fee for service, and risk contracts
  • Intermediate to Advanced proficiency in Microsoft Office applications to include Excel (formulas/data manipulation) and Powerpoint
  • Travel to provider offices within the region approximately 30% of the time
10

Skills For Provider Performance Representative Resume

  • Driver’s license and vehicle are required with ability and willingness to travel within the region up to 50% of the time
  • 20-25% travel in the Central Florida area as needed
  • Intermediate with Microsoft Word, Excel, PowerPoint & Outlook
  • Respond to provider questions and resolves provider issues in order to build and maintain positive provider relationships that foster a collaborative approach to quality care, network stability and cost containment
  • Applies knowledge of basic benefit structures, Consumer Directed, HMO/PPO risk/non-risk and financial arrangements including Medicare Advantage programs in order to answer questions and educate others

List of Typical Responsibilities For a Provider Representative Resume

1

Responsibilities For Provider Enrollment Representative Resume

  • Work special projects, as assigned
  • Implement programs designed to ensure proper application of contracted rates and reimbursement policies for company affiliates
  • Review claim disputes to verify correct pricing and analyze claim inquiry data to determine root cause of errors and recommend system changes, training and process improvements to prevent future errors
  • Identify and solve a range of problems within area of expertise
  • Maintenance activities include, but are not limited to
2

Responsibilities For Provider Reimbursement Representative Resume

  • Perform analysis of claims disputes received, to ensure proper application of financial risk and reimbursement policies and procedures
  • Review claim disputes to determine root cause of errors and recommend contract changes, system changes, and/or training and process improvements to prevent future issues
  • Communicate effectively, verbally and in writing, with various parties, internal and external, to support resolution of member out of pocket inquiries/issues and to ensure appropriate processing of claims and submission of related encounter data
  • Respond to provider inquiries by answering questions and helping them address issues or concerns
  • Document detailed root cause issues and recommend process improvements to prevent future cost share submission delays
3

Responsibilities For Provider Installation Representative Resume

  • Support Provider Consultants and Provider Contracting Executives as needed to ensure effective provider partnerships (e.g. gather data, update systems, research issues)
  • Resolve provider issues in order to build and maintain positive provider relationships that foster a collaborative approach to quality care, network stability and cost containment
  • Validation and maintenance of all provider records within the health plan system(s) this includes: validation of demographic and specialty information on an annual, semi-annual or quarterly basis
  • Assist in ensuring that Provider Directories and regulatory requirements are accurate and that errors are root caused and discussed at the global level to ensure appropriate corrections and improvements are made
  • Travel to local provider offices up to 3 to 4 days weekly
  • Driver’s license and vehicle are required
  • Driver’s license and vehicle are required and ability to travel 30% in the central Florida area
  • Intermediate knowledge of Microsoft Office Excel & Word applications
4

Responsibilities For Provider Contracting Representative Resume

  • Basic/Foundational level of proficiency with Microsoft PowerPoint
  • Basic level of proficiency with Microsoft PowerPoint
  • Has knowledge of iCES, NDB, Onbase, ppoONE, and KL
  • Driver’s license and vehicle are required and ability to travel up to 10% in the Miami area and within the state of Florida at times
  • Travel up to 50% locally in Central Florida
  • Intermediate proficiency with MS Office (Excel, Word and PowerPoint)
5

Responsibilities For Provider Engagement Representative Resume

  • Microsoft Excel proficiency (filter, sort, create and edit spreadsheets)
  • Experience with Microsoft Outlook, Microsoft Word, Microsoft Access, and Microsoft Excel including executing simple formulas; manipulate data; sorting / filtering
  • Proficiency with Microsoft Excel (filter, sort, create and edit spreadsheets)
  • Intermediate proficiency with Microsoft Office (Excel, Word, and PowerPoint)
  • High in-depth knowledge of the health care industry and current events
  • Strong organizational, interpersonal and communication (written and verbal) skills required with the ability to convey ideas to Centralized and Decentralized BU representation
6

Responsibilities For Provider Data Attestation Representative Resume

  • Intermediate level of proficiency with Microsoft Word (create and edit documents) and Microsoft Excel (manipulate and sort spreadsheets)
  • Basic level of proficiency with Microsoft PowerPoint (create presentations)
  • Knowledge of managed care and Medicare concepts
  • Communicate effectively, both orally and in writing, regarding complex or sensitive information or issues, including ability to remain composed in confrontation situations
  • Basic level of proficiency with Microsoft PowerPoint (create presentation)
  • Proficiency with Microsoft Excel (create and edit, sort, filter, format)
7

Responsibilities For Senior Provider Reimbursement Representative Resume

  • Create, edit and save documents in Microsoft Excel, Microsoft Word, and Microsoft PowerPoint
  • Communicate at both an individual and team level
  • Experience with Microsoft Word (create correspondence and work within templates), Microsoft Excel (creating spreadsheets), and Microsoft Access (queries for inconsistencies on various spreadsheets, auditing fee schedules)
  • Create and conduct effective presentations via WebEx
  • Previous experience working with Microsoft Office including Microsoft Outlook (ability to create, edit, save, and send documents), Microsoft Word (ability to create, edit, save, and send documents), and Microsoft Excel (ability to create, edit, save, and send documents)
8

Responsibilities For Representative, Provider Services Resume

  • Previous experience working with Microsoft Access (ability to create, edit and save)
  • Intermediate level of proficiency with PC based software programs and automated database management systems required (MS Excel - spreadsheets, data entry, sorting, filtering and pivot tables)
  • Intermediate level of proficiency with Microsoft Word (create and edit document)
  • Handle a fast paced environment with pressure based on project deadlines
  • Basic level of proficiency with Microsoft Excel and Microsoft Word with the ability to edit, create, and save spreadsheets and documents
9

Responsibilities For Provider Data Entry Representative Resume

  • Working knowledge in the areas of Risk or Value based contracting, Group Practice Management, Long-Term Acute Care, home health, home infusion, behavioral health, ambulatory surgery, and the outpatient experience
  • Services calls and correspondence from providers; identifies and/or responds to inquiries, dissatisfaction, and refers appropriate provider grievances to Special Support for Provider Services. Documents all calls in EXP documentation system
  • Contract interpretation experience
  • Benefit setup experience
  • Applies established protocols to ensure resolution is provided in a clear and accurate manner
  • Facilitates problem resolution and acts as a customer advocate
10

Responsibilities For Provider Performance Representative Resume

  • Identifies provider/member issues and refers them to the appropriate department
  • Reviews phone activity and quality reports to self-monitor performance, quality and productivity standards. Discusses deficiencies/problems with Manager to adjust behavior and work activities as appropriate
  • Maintains a balance of quality, productivity and timeliness of all job responsibilities
  • Follows internal processes and procedures to ensure all activities are performed in accordance with departmental and company standards
  • Driver’s license and vehicle are required and ability to travel up to 50% in the Broward area and within the state of Florida at times

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