Provider Relations Analyst

Job Purpose:

• The Provider Relations Analyst will play a crucial role in analyzing and managing the relationships between the insurance company and healthcare providers.
• This position involves evaluating medical service provider data, ensuring compliance with policies and regulations, and optimizing provider networks to enhance service delivery and operational efficiency.

Key responsibilities:

• Analyze service provider data to identify trends, patterns, and areas for improvement.
• Prepare and present detailed reports on provider performance, utilization, and cost-effectiveness.
• Develop and maintain dashboards and metrics to track key performance indicators (KPIs).
• Evaluate and assess the performance of service providers to ensure adherence to company standards and contractual agreements.
• Collaborate with network managers to optimize provider networks and improve provider relations.
• Conduct regular audits and reviews of provider services and billing practices.
• Ensure compliance with regulatory requirements, company policies, and industry best practices.
• Monitor and address any discrepancies or issues related to provider billing, claims, and documentation.
• Assist in the development and implementation of quality assurance programs for provider services.
• Identify opportunities for process improvements and implement solutions to enhance efficiency and effectiveness.
• Develop and recommend best practices for managing provider relationships and optimizing service delivery.
• Delegated Authority: As per the approved Delegated Authority Matrix.

Key Performance Measures:

• As described in your Personal Score Card.

Knowledge, experience and qualifications required

• Bachelor’s degree in actuarial science, Statistics, Mathematics or a related field.
• Minimum of 2 years of experience in healthcare analysis, insurance, or a related field.
• Strong understanding of medical terminology, healthcare systems, and insurance processes.
• Proficiency in data analysis tools and software (e.g., Excel, SQL, or BI tools).
• Excellent analytical, problem-solving, and critical-thinking skills.
• Strong communication and interpersonal skills with the ability to interact effectively with diverse stakeholders.

Technical/ Functional competencies:

• Knowledge of insurance regulatory requirements.
• Knowledge of insurance products.
• Sales and marketing management skills.