Provider Relations Field Representative II

This is a fully remote position, open to applicants in Pennsylvania.

📋 Description

• Engage with providers through in-person meetings, video calls, phone discussions, and email training, orientation, and coaching.

• Offer assistance with eligibility verification, claims submission, and payment resources.

• Organize monthly and/or quarterly meetings for provider groups, documenting issues, attendees, and action items.

• Investigate claims or prior authorization challenges and escalate them for resolution.

• Work alongside Network Recruitment on provider contracting, responding to inquiries, and conducting network adequacy assessments.

• Partner with Credentialing to manage document intake and address provider credentialing queries.

• Serve as the primary point of contact for assigned provider groups, overseeing relationships and performance.

• Record provider interactions, outreach efforts, office visits, concerns, and resolutions.

• Report on provider claims and directory information both internally and externally.

• Facilitate provider orientation across relevant product lines.

• Promote the use of provider tools, portals, and digital processes.

• Conduct onsite facility reviews and quarterly in-person visits within the designated territory.

• Collaborate with Claims, Customer Service, Utilization Management, Clinical Management, Credentialing, Recruitment, and Account Management teams.

• Educate providers about state programs, group policies, health plan procedures, and regulations.

• Investigate complex provider issues and update provider demographic database details.

• Address contract inquiries, provider education requests, and non-routine claim challenges.

• Maintain precise and timely records for reporting and operational efficiency.

• Represent the organization at work-related events and conferences.

• Mentor and coach junior team members when applicable.

⛳️ Requirements

• Must reside in or be located near Pennsylvania.

• High School Diploma or equivalent qualification.

• 1 to 2 years of experience in a Dental office.

• Understanding of Dental Terminology.

• Intermediate proficiency in Microsoft Office applications, particularly Microsoft Excel, including spreadsheets, databases, word processing, presentation software, and data analysis systems.

• Valid driver's license with proof of auto insurance and capability to use personal vehicle.

• Willingness to travel up to 50% within Pennsylvania.

• Must maintain internet service with a minimum of 25 Mbps download and 25 Mbps upload while connected via a wired connection and not using a VPN.

• Familiarity with health plan operations.

• Understanding of provider/health plan contracts and agreements.

• Ability to monitor provider capacity, performance, and network adequacy.

• Skill in evaluating provider performance and network adequacy metrics.

• Capacity to analyze provider network composition, geographic access, and market conditions.

• Ability to identify recurring provider issues and operational trends.

• Bachelor's degree is preferred.

• DANB or CDA certification is preferred.

• 1 year of experience with the provider credentialing and contracting process is preferred.

• 1 to 2 years of experience in health insurance claims and the ability to analyze data to resolve provider claim issues is preferred.

🏝️ Benefits

• Opportunities for skill-building, leadership development, and philanthropic involvement.

• Comprehensive medical, dental, supplemental health, life, and vision insurance for you and your dependents with no waiting period.

• Life and disability insurance coverage.

• 401(k) plan with company matching contributions.

• Tuition assistance program.

• Paid parental leave.

• Backup family care support.

• Flexible time off policy.

• Flexible dress code and work location options.

• Access to Employee Resource Groups.

• Opportunities for social responsibility and community volunteerism.

• Potential availability of benefits, bonuses, and commissions.