Provider Relations Specialist

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

📋 Description

• Acts as a vital relationship and operational intermediary between the group and the organization’s Care Management/Utilization Management (CM/UM) programs.

• Facilitates provider engagement, education, and problem resolution concerning referrals, prior authorization/intake procedures, and care management initiatives.

• Collaborates with internal UM/CM, Intake, Claims, Network, and Operations teams to ensure providers receive clear guidance, prompt responses, and consistent service—promoting compliant, high-quality care and a positive provider experience.

• Cultivates professional, service-oriented relationships with provider offices, facilities, and ancillary organizations through proactive outreach (phone/email/virtual meetings) and timely follow-up.

• Addresses routine provider inquiries; investigates and resolves issues within established turnaround times, utilizing defined policies, job aids, and escalation processes.

• Offers fundamental education to providers and office staff regarding submission criteria, necessary documentation, timelines, and available CM/UM resources.

• Directs requests to the appropriate internal team (Intake, UM/UR, CM, Claims, Network, Operations) and monitors until resolution; communicates status updates to providers as necessary.

• Accurately document provider interactions, inquiries, and outcomes in designated systems; maintain thorough, professional records.

• Contributes to provider experience initiatives by identifying service gaps, reporting recurring issues, and suggesting updates to job aids or FAQs.

• Instructs providers and office staff on health plan requirements, benefits, prior authorization procedures, and care management programs.

⛳️ Requirements

• High school diploma or equivalent is mandatory; an associate’s or bachelor’s degree in healthcare administration, business, public health, or a related field is preferred.

• At least 1 year of experience in a healthcare administrative, health plan, provider services, call center, or related role (experience in managed care/TPA is preferred).

• Proficient in Microsoft Office (Outlook, Word, Excel) and capable of learning internal platforms and provider portals (e.g., Availity or similar) as needed.

• Basic computer literacy is essential.

• Capacity to work across multiple screens and proficient typing skills are required.

• Exceptional verbal and written communication abilities.

• Ability to articulate complex or technical information clearly and understandably, as well as interpret complex information from others.

• Capability to work independently and leverage resources for problem-solving.

• Higher education degree is preferred.

• Additional skills in the Microsoft suite, including SharePoint and Smartsheet with data analytics, are advantageous.

• Familiarity with the Availity platform is preferred.

🏝️ Benefits

• Competitive base salary and benefits commencing on day one.

• Comprehensive medical and dental coverage through our own health solutions (indeed, we utilize what we create).

• Paid Time Off—time for rest and rejuvenation is essential.

• Mental health support, retirement planning, and financial security.

• Opportunities for professional development with clear career paths and learning budgets.

• Mission-driven culture where diverse perspectives contribute to a meaningful impact on individuals' health.