Member and Provider Relations Specialist

Prime Healthcare

Job Description

The Member and Provider Relations Specialist is responsible for the daily management of member and provider relations, including appeals, utilization management and case management.  Generate correspondence upon review of cases to resolve all inquiries as it pertains to claims appeals, member grievances and provider network management.  Assist in the development of training manuals, policies and training of new team members.  Collaborate with internal leadership, teams and partners. Support special projects for the department as designated by Manager to forward the goals of the Employee Health plan to deliver high quality, value based care and exceptional service to members and providers.





Required qualifications:


1.    High School Graduate or GED

2.    Knowledge of medical claims, appeals and grievances, and member and provider relations.

3.    Working knowledge of self-funded medical plans and/or managed care plans

4.    Strong customer service, oral and written communication skills

5.    Excellent communication, organizational, and analytical skills

6.    Strong computer skills incl. MS Office skills




We are an Equal Opportunity/ Affirmative Action Employer and do not discriminate against applicants due to veteran status, disability, race, gender, gender identity, sexual orientation or other protected characteristics. If you need special accommodation for the application process, please contact Human Resources.  EEO is the Law: