Provider Operations SpecialistJob Description, Salary, Career Path, and Trends

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.

Sample job description #1

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 include but are not limited to:

  • 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

Sample job description #2

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.

Key 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

Sample job description #3

Essential duties and responsibilities include the following:

  • 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

Average salary and compensation

The average salary for a provider operations specialist is $49,950 in the United States. Position salary will vary based on experience, education, company size, industry, and market.

LocationSalary LowSalary High
Phoenix, Arizona$49,650$67,200
Los Angeles, California$56,050$75,800
Denver, Colorado$46,700$63,150
Washington, DC$56,850$76,950
Miami, Florida$46,450$62,900
Orlando, Florida$42,850$58,000
Tampa, Florida$43,300$58,550
Atlanta, Georgia$45,450$61,450
Chicago, Illinois$52,250$70,650
Boston, Massachusetts$56,450$76,350
Minneapolis-St. Paul, Minnesota$45,000$60,850
New York City, New York$59,450$80,450
Philadelphia, Pennsylvania$48,400$65,450
Dallas, Texas$47,100$63,750
Houston, Texas$46,900$63,450
Seattle, Washington$54,350$73,500
National Average$42,450$57,450

Sample interview questions

  • What would you say your most beneficial skills are for the role of provider operations specialist?
  • What makes you beneficial for our team?
  • Would you say you have strong communication and trust-building skills?
  • Do you have any experience with claims?
  • Do you know the default setting and templates for forms and hospital claims?
  • Why do you want to work as a provider operations specialist here specifically?
  • What relevant certificates, if any, do you have for a position as a provider operations specialist?
  • How do you keep patient information confidential? 
  • How familiar are you with HIPAA?

Provider Operations Specialist Jobs in Ashburn

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