Provider Relations Representative

POSITION SUMMARY / RESPONSIBILITIES

Provider Relations Representative works as the primary liaison between Community First Health Plans and network participants (physicians, providers, and administrators) of the health plan provider network. This position will build and nurture positive relationships with health plan network participants by providing the on‑boarding orientation, and delivering guidance and high‑quality service through regular engagement by phone and through scheduled in‑person visits to targeted provider offices. This position will also coordinate with Compliance & Quality staff on the re‑credentialing process; with Provider Contracting staff for contracting issues or concerns; and will periodically assist the Claims staff with auditing and troubleshooting of provider data to ensure proper claims adjudication. The Provider Relations Representative knows and abides by all organizational and departmental policies, sets personal standards, and strives for high quality work in completing assignments, performs job duties in a timely manner, and represents the organization in a positive manner.

EDUCATION / EXPERIENCE

A minimum of five years of related experience in the healthcare or managed care field of customer service‑related work is required. Bachelor’s degree in business, healthcare, communications, or other related area is preferred. Recent experience as a provider relations representative, member service representative, or relevant claim experience is highly preferred.

LICENSURE

Valid Texas driver’s license as well as a reliable vehicle is required.

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