Provider Relations Representative

The Provider Relations Representative evaluates assigned territories and is responsible for recruiting, contracting, and maintaining relationships with physicians, specialists, ancillary providers, and hospitals to support a high-quality, cost-effective provider network.

Key Responsibilities:

• Identify and target potential providers to establish contractual agreements aligned with network needs.
• Analyze and evaluate assigned territories to determine provider recruitment gaps and opportunities.
• Recruit and contract physicians, specialists, ancillary providers, and hospitals, ensuring completion of all required documentation, including credentials and site visits.
• Conduct site visits for all newly contracted providers to verify compliance with network and regulatory standards.
• Negotiate provider contracts and reimbursement rates using utilization and claims data to support financially sound agreements.
• Serve as a primary point of contact for provider inquiries related to contracts, network participation, and Health Network One operations.
• Collaborate with contracted providers to integrate services into the overall care delivery network.
• Maintain effective communication with internal departments and participating providers to support network development and provider referrals.
• Support the Credentialing Department by assisting with the collection and maintenance of credentialing and re-credentialing documentation.
• Maintain accurate and up-to-date provider files and ensure data integrity in company systems and databases.
• Analyze claims and utilization data for newly contracted providers to evaluate performance and contract profitability.
• Prepare reports and summaries for presentation to senior management.
• Ensure compliance with HIPAA regulations and all company policies and procedures.
• Perform additional related duties as assigned.

Required Qualifications:

• Associate’s degree or equivalent from an accredited two-year college or technical school, or an equivalent combination of education and experience.
• Two to three years of experience in a physician office, HMO, managed care organization, or other healthcare environment.

Preferred Qualifications:

• Experience in provider contracting, network management, or managed care operations.
• Familiarity with claims analysis, utilization data, and provider reimbursement structures.

Location/Travel:

• Remote, may require travel within territory based on network needs

Originally posted on Himalayas