Job Profile Summary
Position Purpose:
Perform duties to act as a liaison between providers, the health plan and Corporate including investigating and resolving provider claims issues. Perform training, orientation and coaching for performance improvement within physician practices.
Education/Experience:
High school diploma or equivalent. Bachelor s degree in healthcare related field preferred. 3+ years of sales, provider relations, or contracting experience. Knowledge of health care, managed care, Medicare or Medicaid. Claims billing/coding knowledge preferred. Driver s License may be required by some plans. Specific language skills may be required by some plans.
- Serve as primary contact for providers serving as a liaison between the provider and the health plan
- Conduct meetings with the providers documenting discussions, issues, attendees, and action items researching claims issues on site and routing to the appropriate party for resolution
- Receive and respond to external provider related issues
- Initiate entry or change of provider related database information and oversee testing and completion of change request
- Investigate, resolve and communicate provider claim issues and changes
- Educate providers regarding policies and procedures related to referrals and claims submission, web site education, EDI solicitation and problem solving
- Perform provider orientations, including writing and updating orientation m Mayra Valenzuela aterials
- Performs other duties as assigned
- Complies with all policies and standards
|
| Story Behind the Need |
- What is the purpose of this team?
- What is driving this need? (ex. Backfill for FTE or CW, new project, business growth)
- Describe the surrounding team (team culture, work environment, etc.) & key projects.
- Do you have any additional upcoming hiring needs, or is this request part of a larger hiring initiative?
| The Provider Relations team serves as the primary liaison between Centene Dental and its participating provider network. The team is responsible for building and maintaining strong provider relationships, resolving provider concerns, supporting network adequacy initiatives, facilitating provider education, assisting with onboarding activities, and ensuring providers have the tools, resources, and information necessary to successfully partner with the health plan. The team's overall goal is to enhance the provider experience while supporting quality access to care for our members.
This position is being requested as a backfill for an existing FTE
The Provider Relations team operates in a highly collaborative, service-focused environment that values teamwork, responsiveness, accountability, and provider satisfaction. Team members work closely with Network Management, Credentialing, Claims, Operations, Contracting, and other internal departments to resolve provider issues and improve provider experiences. The culture emphasizes partnership, proactive communication, compliance, continuous process improvement, and delivering exceptional service to providers.
Key projects and responsibilities include:- Managing provider relationships and territory assignments.
- Conducting provider onboarding and welcome outreach.
- Resolving claims, authorization, and operational escalations.
- Reviewing provider data and network adequacy reports.
- Delivering provider education, training, and webinars.
- Supporting provider surveys and satisfaction initiatives.
- Collaborating with internal departments to improve processes and provider experience.
- Conducting proactive outreach to support provider retention and network growth.
At this time, this request is intended to fill a current Provider Relations Representative vacancy
|
| Typical Day in the Role |
- Walk me through the day-to-day responsibilities and a description of the project (Outside of the Workday JD).
- What are performance expectations/metrics?
- What makes this role unique?
| - Managing provider inquiries and resolving issues related to claims, authorizations, credentialing, eligibility, and provider data.
- Conducting provider outreach through phone calls and email follow up
- Reviewing claims and authorization denial trends and collaborating with operational teams to identify and resolve root causes.
- Providing education and training on policies, procedures, provider manuals, and self-service tools.
- Supporting provider onboarding and conducting welcome calls for newly contracted providers.
- Tracking provider issues, escalations, and resolutions through established ticketing systems.
- Partnering with Claims, Operations, Network Management, Credentialing, and other departments to coordinate issue resolution.
- Supporting provider satisfaction initiatives, surveys, webinars, and educational outreach programs
Success in this position is measured through a combination of productivity, quality, provider satisfaction, and operational metrics, including: - Timely response and resolution of provider inquiries and escalations.
- Achievement of outreach goals, including provider visits, onboarding calls, and educational activities.
- Accurate documentation and tracking of provider interactions and issue resolution activities.
- Completion of assigned reports, audits, and follow-up activities within established timeframes.
- Provider satisfaction and relationship management outcomes.
- Compliance with company policies, regulatory requirements, and documentation standards.
- Effective management of assigned territory and provider portfolio.
- Collaboration with internal partners to improve provider experience and operational performance.
- Ability to manage multiple priorities while maintaining accuracy and service excellence.
This role is unique because it combines relationship management, problem-solving, provider education, and operational collaboration into a single position. Provider Relations Representatives serve as trusted advisors to dental providers while also acting as advocates internally to help resolve issues and improve processes.
|
| Candidate Requirements |
| Education/Certification | Required: bachelors | Preferred: |
| Licensure | Required: NA | Preferred: |
Years of experience required: 3-5 years experience
Disqualifiers:
Additional qualities to look for: Team Player, organized, willing to learn |
- Top 3 must-have hard skills stack-ranked by importance
| 1 | Dental office experience |
| 2 | Provider Relations Experience |
| 3 | Microsoft office |
| Candidate Review & Selection |
- Shortlisting process
- Candidate review & selection
- Interview information
- Onboard process and expectations
| Projected Manager Candidate Review Date: | 1-2 days post shortlisting |
Type of Interviews:
| Teams |
| Required Testing or Assessment (by Vendor): | Typing test, basic computers skills test, etc. |
| Next Steps |