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Financial services representative • clovis ca

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Provider Relations Representative, Insurance Services

Provider Relations Representative, Insurance Services

Community Medical CentersFresno, CA, United States
[job_card.variable_days_ago]
[job_preview.job_type]
  • [job_card.full_time]
[job_card.job_description]

Job Title

Provider Relations Representative

Job Description

The Provider Relations Representative is responsible for addressing provider issues, applying resolutions, and responding to inquiries in an accurate and timely manner for both participating and non-participating providers. The Provider Relations Representative trains new and existing providers in accordance to Community Care Health (CCH) policies and procedures and completes provider on-site audits. Additionally, this position delivers provider relations support to internal departments, including but not limited to Contracting/Network Management, Quality, Compliance, and Medical Management. The provider representative also leads small projects for the department.

Key Responsibilities:

  • Field Liaison: Acting as the "go-between" for the health plan and providers.
  • Field Presence: Out of the office regularly, interfacing directly with the provider community.
  • Education: Meeting with office staff to teach them how to use the portal, check eligibility, and understand prior authorization policies.
  • Problem Resolution: Triaging provider issues (claims, authorizations, eligibility) and following through with internal departments (Claims, UM) until resolved.
  • Data Integrity: Working with Provider Network Ops to audit and update the provider directory.

On-site (Base office at Shaw) when not traveling to providers offices. This position will have heavy field travel to provider offices.

Qualifications

Education:

  • High School Diploma, High School Equivalency (HSE), or Completion of a CHS Approved Individualized Education Plan (IEP) Certificate required
  • Bachelor's Degree in Business or Healthcare Administration required
  • Equivalent combination of education and experience may be substituted for the Bachelor's Degree requirement

Experience:

  • 2 years of experience in managed care, physician office, or health plan environments required
  • Health Plan experience is highly preferred to navigate internal issue resolution.
  • Local candidates are a major plus (those with existing local provider relationships).
  • Experience preferred for core systems: QNXT (will train), Word, and basic Excel (for tracking visits).
  • High-level presentation skills, patience, and strong listening/articulation abilities preferred.

Disclaimers

Pay ranges listed are an estimate and subject to change.
If any bonuses are noted, they are only applicable to external hires meeting criteria.