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How to Become a Provider Operations Specialist

Are you a detail-oriented person who likes working with people and helping them with their questions and issues? A position as a provider operations specialist may be right for you.

Provider operations specialists are responsible for acting as a liaison, working with insurance providers, and helping to resolve issues related to claims. They also help tie so many aspects together, including analyzing data, maintaining contracts, and assisting insurance providers with questions they may have.

Provider operations specialists can work in physician’s offices, hospitals, or other health care and wellness facilities.

Sample job description

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

Typical work environment

Provider operations specialists will work in the healthcare and wellness fields. This can include a position in a hospital, a clinic, a consultation office, or other similar locations. This position will normally be a full-time position with paid benefits. Provider operations specialists are required to work with insurance companies and providers and resolve any disputes which may arise. A provider operation specialist may be required to handle uncomfortable confrontations and occasional interpersonal issues, which means that the provider operations specialist should have excellent communication and conflict resolving skills. Typical responsibilities may be assisting a field rep to resolve claims, answering phone calls and resolving issues, and assisting supervisors with any occasional tasks beyond the common tasks delegated to this position.

Typical hours

The typical work hours for a provider operations specialist can be from 9 AM to 5 PM, Monday through Friday, in an office setting.

Available certifications

Provider operations specialists often are not required to have certifications, though a certification can be useful when applying for a new position. Some common certifications may be:

  • 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 which are certified. Having a certification in this field can be immensely useful to a provider operations specialist looking to amplify their experience.

Career path

The career path for a provider operations specialist starts by first obtaining a high school diploma or GED, as well as having a minimum of one year of experience in customer service or claims. This path often starts as an entry-level position but can have opportunities for ongoing advancement, based on experience and performance.

US, Bureau of Labor Statistics’ job outlook

SOC Code: 29-9098

2020 Employment81,400
Projected Employment in 203089,900
Projected 2020-2030 Percentage Shift 11% increase
Projected 2020-2030 Numeric Shift8,600 increase

The health care industry is generally increasing in size year after year. More people are accessing health care services and making insurance claims for those services, which creates a growing need for provider operations specialists.

One reason for this is the aging population in the United States. Older people typically need more health care than young people. As the oversized baby-boom generation ages, the demand for health care services generally increases across the board.