Under the supervision of the Director of Provider Relations, the Provider Relations Specialist supports contracting, credentialing and provider management activities of the plan. Provides staff support to the Provider Relations Department as applicable and assists with the verification of credentials for practitioners and facilities.
Handles incoming telephone calls and answers questions from providers related to credentialing, billing, contracting and provider issues.
Initiates process of initial credentialing applications, including but not limited to the review and verification of information submitted by providers by utilization of mail, telephone and database queries.
Initiates process of credentialing current network providers, including but not limited to the review and verification of information submitted by providers by utilization of mail, telephone and queries.
Prepares wage parity and other provider information for submission to regulatory agencies and Compliance Department.
Ensures current maintenance and updating of all associated files and records, both computerized and hard copy.
Assists in resolving provider related complaints and grievances.
Provides plan information to new members, family members, other representatives, VCM staff and providers. Responsible for the routine auditing of files to maintain quality.
Assist in preparation and quality review of the provider directory.
Assists with contract preparation and mailing.
Prepares and implements Provider Relations Department mailings.
Specific projects and goals are assigned with some latitude for decision making and setting of priorities.
Minimum formal education of High School Diploma
Minimum of 3 years job-related experience