What Does a Provider Operations
Specialist Do?
Provider operations specialists work with insurance providers to resolve issues related to claims. This includes investigating and analyzing data, maintaining and updating contracts, and assisting insurance providers with questions they may have. They often must resolve customer complaints and should be able to maintain composure in stressful conditions. They enter provider information into the database and work to ensure that claims payments are accurate. They must adhere to all requirements, rules, and regulations. Good communication skills are essential as they work with a number of providers during the course of a day.
Provider operations specialists must have excellent customer service skills and phone etiquette when assisting internal and external customers with claims issues. Competency in working with computers and databases is a requirement. They should also have strong problem-solving skills. Provider operations specialists typically work in physician’s offices, hospitals, or other health care and wellness facilities.
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National Average Salary
Provider operations specialist salaries vary by experience, industry, organization size, and geography. To explore salary ranges by local market, please visit our sister site zengig.com.
The average U.S. salary for a Provider Operations Specialist is:
$79,950
Provider Operations Specialist
Job Descriptions
Crafting the perfect job description may be the key to finding an exceptional provider operations specialist. To help you with your recruiting search, our team has put together some examples from past openings.
Example 1
We’re looking for a provider operations specialist! Our team at [Your Company Name] needs a new provider operations specialist to join our ranks. You will be responsible for communicating with clients and patients. You’ll be in charge of communicating with insurance providers and settling any claims which may be made. This means you will have to have a good head for data input. Daily operations for the ideal candidate will include field representatives in order to resolve any issues and solve any claims. The ideal candidate will have good problem-solving skills and be able to determine and fix any issues which may arise. This position is full-time with reasonable compensation. If this job as a provider operations specialist sounds like it fits you perfectly, please consider applying for the position.
Typical duties and responsibilities
- Support the provider relations field reps to resolve claims and payment issues
- Answer incoming telephone inquiries from providers and assist with the problem-resolution of issues
- Analyze the root causes of operational and health services issues
- Review and process incoming and outgoing paperwork, including directory updates, provider credentialing applications, contract maintenance forms, and other related forms
- Provide office, project management, provider recruitment, and data analysis support
- Assistance with special projects as assigned or directed
Education and experience
This position requires a high school diploma or GED; at least one year of experience in customer service or claims is preferred.
Required skills and qualifications
- Adaptable in a fast-paced and changing environment
- Strong time management skills
- Excellent verbal and written communication skills
- Create Excel pivot tables and v-lookups
Preferred qualifications
- 3+ years experience working in healthcare
- Strong written and verbal communication skills
- Ability to de-escalate upset customers when their claims don’t go through
- Knowledge of health insurance and common claims
Example 2
ABC Company is currently seeking a Provider Operations Specialist to join the team! This role plays a critical part in helping ensure that all inbound provider-related issues for a designated region are addressed and resolved in a timely fashion. This directly impacts the experience of the members, providers, and third party administrators that use our core product.
Responsibilities:
- Resolve all inbound/reactive network related issues/escalations from members/providers/internal TPAs, specifically related to physicians/ancillaries within a timely fashion
- Set up new providers contracts/fee schedules, processing provider related changes, addressing provider/member/issues
- Educating physicians/office staff on the fact that they are contracted
- Verifying whether a physician is in-network, based upon a request from the customer service team
- Updating provider systems with new provider demographic information. (e.g. new TINs)
- Answer physician’s general information questions and send physicians information they are seeking (e.g. member ID cards)
- Respond in a timely manner to physician inquiries regarding contracting requests
- Ensure all provider data/contracts are quickly and appropriately updated in relevant systems
- Ensure loading/removing of new/terminated contracts in all relevant systems
- Process provider demographic/data updates, terminate providers as directed, store information in relevant systems
- Ensure organized storage of all relevant provider documents
- Support network manager/network director in all contracting/management related issues and resolution
Required experience/education:
- Bachelor’s Degree preferred
- 1+ years of previous health insurance/network experience
- Previous provider relations experience preferred
- Proficient in the MS Office Suite to include MS Word, Excel, and Outlook
Example 3
ABC Company is searching for a Provider Operations Specialist to join our growing Business Development team. This individual will play a key role in growing ABC Company’s Managed preferred service provider programs, where we invite the best service providers to be recommended to complete work orders for enrolled clients. You will work closely with our service providers to provide the support they need to take full advantage of these developing programs and the steps required to become a ABC Company preferred provider.
Responsibilities
- Onboard approved service providers to ABC Company’s SC Managed program
- Build strong relationships with service providers, enabling you to be the eyes and ears of the Managed programs
- Coach and develop participating service providers, helping them improve their performance metrics and increase their opportunities within each program
- Collect service provider feedback on the Managed programs, enabling an environment of continuous improvement for our products
- Assist providers with managing their ABC Company’s profile to ensure their services are accurate and up to date on an ongoing basis
Required skills & experience
- The energy and desire to build relationships with service providers daily
- Willingness to learn, advance, and engage with other members to obtain team excellence
- A demonstrated ability to provide support and guidance on fundamental computer applications and product specific technical questions, particularly in a fast-paced environment
- Strong attention to detail and organizational skills to manage multiple accounts
- Ability to quickly learn new tasks, software solutions, and adapt to changes as needed
- Strong work ethic with the ability to work independently from home with a strong record of attendance and punctuality
- Excellent communications skills, both written and verbal
- Minimum of 3 years of customer service work experience
- Google Suite and Microsoft Office experience
Example 4
Essential duties and responsibilities
- Validate and uphold the integrity of provider database adhering to SB-137 compliance
- Act as liaison between internal departments (Contracting, Credentialing, Provider Relations, Terms and Conditions, Eligibility, PDM), and external (Health Plans) entities to effectively communicate and follow-up in a timely manner to resolve provider inquiries and requests
- Verify contract rates and/or fee schedule input correctly for vendors and providers
- Review providers add, termination, and demographic update requests
- Maintain and update providers’ health plan unique identification numbers across all lines of business
- Identify providers’ data error and coordinate with responsible parties to correct
- Accurately log all provider’s requests and be able to provide monthly summary to Director and Team Lead
- Audit providers’ membership assignment based on Shared/Full Risk contract and PPG codes
- Adhere to corporate standards for performance metrics, data integrity, and reporting format to ensure high quality, meaningful output
- Validate IPA and Health Plan Rosters
- Perform other duties as necessary or assigned by the Director or Team Lead
Qualifications
- Knowledge of MS Word, Excel, and basic medical terminology is required
- Ability to understand and work with proprietary software applications
- Organizational ability and ability to exercise good judgment
- Typing speed 30+ WPM and knowledge of 10 key desired
Education and/or experience
- Associate’s degree or High school diploma
- At least 5 years of experience working in the HealthCare Industry and must have experience with Provider, IPA, or Health Plans communications
- Knowledgeable with the different type Lines of Businesses provided by Health Plans in (State)
- Must have experienced working with excel, accounting, clerical, and office setting, or related experience and/or training; or equivalent combination of education and experience
Candidate Certifications to Look For
- Relevant Degree. Although the provider operations specialist field does not commonly have any certifications, having a relevant degree can be extremely beneficial to gain access to this field. This degree will be one pertaining to medical or insurance fields in order to provide the most benefit.
- Certified Provider Operations Specialist. A certified provider operations specialist will be able to showcase their competency in the field of provider operations, which includes the basic level of competency required and any more advanced aspects that are certified. Having a certification in this field can be immensely useful to a provider operations specialist looking to amplify their experience.
Sample Interview Questions
- In what ways can you ensure that provider networks are managed effectively and that patients and healthcare providers are met?
- How did you increase efficiency and reduce costs in healthcare operations by identifying and implementing process improvements?
- How do you maintain and build relationships with stakeholders and healthcare providers?
- Do you know the default setting and templates for forms and hospital claims?
- What methods do you use to measure and report provider network performance, and how have you identified areas for improvement?
- How have you dealt with resource constraints and technological limitations in healthcare operations?
- What strategies have you used to overcome compliance challenges related to healthcare regulations and industry standards?
- Can you share an example of when you had to manage multiple tasks and responsibilities in healthcare operations and how you prioritized and met deadlines?
