Manager, Provider Relations

• Manage relationships with assigned hospitals
• Serve as a primary point of contact for provider operational issues, inquiries, and escalations
• Investigate and resolve complex provider concerns related to claims, rework, appeals, provider data, credentialing, and reimbursement issues
• Partner with Claims, Appeals, Operations, Provider Data, Credentialing, Medical Management, and Contracting teams
• Analyze provider service trends, operational performance, and issue root causes
• Support provider performance initiatives related to quality, access, operational efficiency, and member experience
• Educate providers on health plan programs, administrative processes, self-service tools, and operational requirements
• Support value-based care initiatives through provider engagement, education, and operational support
• Assist with network adequacy activities, provider recruitment efforts, and regulatory initiatives
• Research and respond to provider complaints, disputes, executive escalations, and regulatory inquiries
• Monitor provider issues through resolution and communicate status updates to internal and external stakeholders
• Support implementation of network and operational initiatives impacting providers
• Prepare provider-facing materials, business summaries, issue analyses, and leadership updates
• Ensure compliance with contractual requirements, regulatory standards, and company policies
• Support special projects and cross-functional initiatives as assigned

• 4+ years of experience in healthcare operations, provider relations, network management, managed care, claims, provider services, or related healthcare experience
• Demonstrated experience working directly with physicians, hospitals, ancillary providers, or healthcare organizations
• Experience researching and resolving complex operational or provider-related issues
• Strong analytical and problem-solving skills
• Understanding of healthcare operations including claims processing, provider enrollment, credentialing, provider data management, and reimbursement fundamentals
• Ability to collaborate effectively across a highly matrixed organization
• Strong verbal, written, and presentation communication skills
• Ability to manage multiple priorities simultaneously and deliver results in a fast-paced environment
• Proficiency with Microsoft Excel, PowerPoint, and data analysis tools
• Bachelor's degree or equivalent combination of education and relevant professional experience

Demonstrates expertise in healthcare operations, provider relations, and claims processing, with a strong focus on analytical problem-solving and effective communication. Capable of managing provider performance initiatives and ensuring compliance with regulatory standards.

• Healthcare Operations Experience
• Provider Relations Management
• Claims Processing Knowledge
• Analytical Problem-Solving Skills
• Strong Communication Skills

• Claims Processing
• Provider Enrollment
• Credentialing
• Provider Data Management
• Reimbursement Fundamentals
• Data Analysis
• Operational Performance Analysis
• Issue Resolution
• Network Management
• Value-Based Care Initiatives

• Collaboration
• Problem-Solving
• Time Management
• Presentation Skills
• Verbal Communication

• Healthcare
• Provider Services
• Managed Care
• Network Adequacy
• Regulatory Compliance

• Microsoft Excel
• Microsoft Power Point
• Data Analysis Tools