Providers is a generic term used to describe health professionals, such as doctors, dentists, advanced practice registered nurses, physician assistants, and others who provide direct care and bill for services. Support staff, such as medical assistants or dental assistants, are not included in this category. A provider relations representative or manager is the customer support person for an insurance company who works with providers, rather than patients.
Important Skills and Characteristics
A provider relations representative must have strong communication skills. A rep must be able to discuss all aspects of the organization's insurance network, negotiate with providers and explain anything that is unclear. She must be able to listen carefully to a provider’s concerns and draw on good interpersonal skills to build rapport. A rep must be patient and remain polite even when dealing with an angry provider. Problem-solving skills and computer proficiency are also required in this role.
It's All in the Negotiations
A provider relations representative negotiates the contracts with healthcare professionals who provide services to the insurance network’s clients. Her primary responsibility is to complete negotiations in a way that satisfies providers -- who want to be reimbursed fairly -- while staying within the insurance company’s financial restraints. She reviews and revises contracts, and ensures that all necessary documentation is complete and correct. Provider relations reps often maintain provider databases for their organization and departments.
Provider relations reps handle complaints from patients and providers. They develop letters of agreement, maintain provider documentation files and periodically perform a financial analysis related to provider contracts. The provider relations rep is often the expert resource for other staff on contract issues. She maintains documentation on claims against network providers and may make recommendations to executive leaders regarding provider contracts. Some provider reps might also train providers and their staff regarding insurance network policies or procedures.
Preparing for the Job
Although the U.S. Bureau of Labor Statistics reports a high school diploma is sufficient for a customer service representative job, insurance companies might require a bachelor’s degree in business or healthcare administration. Some companies, such as Health Share of Oregon, prefer a master’s degree. The job typically requires on-the-job training as well. In some states, the BLS notes, a provider relations rep might need a license, which usually requires passing a written exam.