Running head: A CAREER IN PROVIDER RELATIONS

e-Portfolio Term Project

Provider Relations Manager
Bret Gashler
Salt Lake Community College

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A Career in Provider Relations

I have chosen to study the career of a Provider Relations Manager. My reasoning for
focusing on this field comes from my current and past employment in both the medical and
business industry. For a short time following my graduation from high school I worked in
several different nursing homes and home health agencies as a full-time Certified Nursing
Assistant. I learned fairly quickly that working as a CNA was not what I wanted to do long-term,
however, the job also helped me realize my interest in the medical field and that I wanted to
direct my career path towards something in the medical and health sciences. After exploring
various other employment opportunities over the years I landed at my current employer, Deseret
Mutual Benefit Administrators. This position was a great fit as it combined two of my top
interests: the medical field and business management. My background experience as a CNA and
my experience in customer service helped quickly grasped the concepts of health insurance and
my overall objective as an employee of DMBA.
I quickly excelled and moved into a leadership position in the Member Services
Department as a Customer Service Specialist where I was responsible for managing a team of
employees handling claim and benefit conflicts and questions from customers. After becoming
familiar with my role, I began to focus my thoughts upon where I wanted to end up in the
company. There are many moving pieces to a health benefits company so thankfully I had many
options to choose from. The department I have been most interested in is the Healthcare
Services Department, which contains the Provider Contracting team. The autonomy and degree
of trust to work on your own initially attracted my interest in this field. I also enjoy the possible
aspect of traveling to different locales and working face-to-face with healthcare providers. The

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average salary is also very attractive aspect of this career as I have evaluated my financial needs
for myself and future family.
Job Description
A Provider Relations manager has a wide range of responsibilities within a health
insurance company. According to Salary.com, a Provider Relations Manager develops,
manages, and sustains relationship with managed care service providers (2016). More
specifically, they are responsible for all contracts with physicians and facilities, determining or
assisting with creating pay scales for services, creating and maintaining positive relationships
with providers, managing the Provider Relations team, and assisting with reviewing data
pertaining to healthcare claims and billing.
There is a great amount of responsibility that falls upon a Provider Relations Manager.
Not only are they are responsible for keeping providers and all contracted health facilities
satisfied, but they are also in charge of attending to the needs of their individual Provider
Relations team. This presents a problem if one is not proactive and well organized. Many
managers will divvy the workload of provider contracting amongst his or her team. This is
usually organized according to geographical regions. One team member will be responsible for
all facilities and providers south of a certain area, while another may be in charge of all hospitals
specializing in mental health services. Effective delegation in these areas can help alleviate a
great deal of pressure from the manager.
Another important responsibility of the Provider Relations Manager is acting as a liaison
between the insurance company and the respective health care providers. They must make sure to
create contracts and pay rates that are appealing to both the doctors and hospitals along with

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working in the best interests of the insurance company and its members. This can be a very
difficult and complex process as each party wants what is most beneficial to them. Education
plays a key role in remedying this. The Provider Relations Manager should be sure to provide all
pertinent information to providers before and during contracting, and negotiation. If there are
any changes in the company that may affect payment or current contract status, the manager
must communicate with those impacted.
General Career Path/General Education Experience
The general path someone would follow to become a Provider Relations Manager would
be attaining a degree in higher education in a field relevant to business, marketing, or healthcare.
A bachelors degree is required by many organizations for employment; in fact, at least one third
of managers surveyed at Salary.com reported having obtained at least a four-year degree, while
another one third obtained a masters degree (2016). Many sources and employers also state that
applicants must have at least five years of experience in a related field like business
management, finance, analytics, etc.
There is the possibility that an existing employee without such a detailed background
could remain in a company and eventually be promoted to the position of Provider Relations
Manager, but these instances are rare, as the experiences in healthcare and other arms of business
and finance greatly contribute to making the employer an efficacious manager. A future
employee must prove themselves able to handle the rigors and difficulty of the position. One
way that companies can do this is by hiring someone that has graduated from college and has
sufficient experience in management and/or healthcare.

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Average Salary
One of the benefits of working as a manager in this field is the ability to make a decent
salary, especially in a larger insurance company. Pay can be widely influence by work experience
and location. According to the website Payscale.com, Provider Relations Managerial staff pay
ranged from $46,000 all the way up to $93,000. The average salary is in the area of $66,000 per
year (Salary.com, 2016).
Career Outlook
Both healthcare and health insurance are growing industries. The career outlook posted
by the Bureau of Labor Statistics states that, as more people get health insurance coverage, the
number of people seeking routine medical care is expected to grow. In turn, more jobs are
projected to be added for workers who treat these people, including those who provide medical
insurance coverage for patients (2014). Healthcare is a necessity, and the new laws resulting
from healthcare reform make insurance a necessity, meaning the career outlook for everyone in
healthcare and insurance is likely to be very positive within the coming years and even decades.
Bio of Someone in the Profession
I recently interviewed Sione Fisihetau from my company, Desert Mutual Benefit
Administrators, to gather more personal information on a career in provider relations and
insurance contracting. He has been with the company for two years now after having studied
Finance at BYU Hawaii. He was interested in data analytics and learned that it was extremely
useful in the health insurance world, which led him to apply to DMBA.
The world of health insurance is complicated, thus making the position of handling
provider relations also complex. Sione explained that some of the bigger challenges he faces

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include the fast pace and ever-changing health market we live in. Providers are constantly
adding and dropping providers, pharmaceutical companies continuously change their prices, and
knowing the government rules and regulations is a task in and of itself. He also mentioned that
he and his team are somewhat responsible for finding physicians and healthcare providers that
are fraudulently billing insurance providers, which was something I had never thought of as a
responsibility of this position.
Work ethic, problem solving, initiative, knowledge of the industry, and the ability to
communicate effectively are the vital skills needed to be a successful provider relations manager.
The job allows for a great deal of autonomy, but also comes with heavy responsibility, making
initiative and a solid work ethic top priority. Youre expected to get the job done no matter
what, Sione says, Im given the freedom to manage my time and the providers I oversee
however I see fit, but I still answer to DMBA at the end of the day.
The world of provider relations also encompassed more than I had originally thought
when I first became interested in this career. Cost-cutting projects is another aspect of Siones
job that I was unaware of. Part of his responsibilities within negotiating these provider contracts
is finding ways to decrease the cost of healthcare services and make the pricing more transparent
to recipients and insurance members before they actually receive the service. This project is
thought to help lower healthcare costs to both insurance companies and members through
avoiding unnecessary treatments and services before they happen and must be billed through the
private insurance company, Medicare, Medicaid, etc. Another challenge briefly mentioned by
Sione that I researched afterwards stated that providers with more experience also have more
leverage when negotiating contracts, making it more difficult to reach a consensus. Fee

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schedules are often negotiable, particularly if the [physician] has a substantial practice or other
attractive attributes that give the pediatrician leverage with the health plan (AAP, 2016).
Pros and Cons
The positive aspects to a career in provider relations include a great deal of autonomy,
which is important to my job satisfaction, and a good number of new opportunities. Larger
amounts of autonomy in a job tends to lead to an increased level of satisfaction because workers
have more freedom to determine their own effort and work schedule (Ngyuen, Taylor, Bradley
2003). The healthcare market is constantly changing and evolving, causing the role of a manager
in provider relations to constantly do the same. Fortunately, this means that the job will always
include something different, making the workday go by more quickly. This is a career in which
it is impossible to be stagnant, which would drive me to work very hard. It is also a career in
which progress is evident, which definitely helps my feelings of self-worth and job satisfaction.
Unfortunately, the changes in the healthcare market could mean some unpredictability in
the career, especially with universal healthcare where government contractors may have a larger
role in contracting physicians and other providers. Another downside to this career path is the
constant pressure to always be solving problems quickly. It can be difficult to come up with new
ideas and it is definitely not always easy to reach a compromise that can result in a contract in
which all parties, the insurance company, provider, and patient, will all mutually benefit from.
There are a large number of potential problems that could arise if the job is not done correctly.
Your Fit with this Career
As mentioned before, this career feels to be a good mix between my interests in both
healthcare and business management. The work this job contains would make me feel like a

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contributing member of society, as I would know that my work is going towards helping improve
the quality and cost of care for customers of my company. The skillset required to work in this
field also caters very well to my strengths and interests; I enjoy hard work, problem solving,
negotiating, communicating, and appreciate a certain degree of autonomy and trust in my job.

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Works Cited

Fisihetau, Sione. Personal communication, July 20, 2016.

Managed Care Contract Issues. (2016). Retrieved July 21, 2016, from https://www.aap.org/enus/professional-resources/practice-support/financing-and-payment/pages/Managed-CareContract-Issues.aspx?nfstatus=401

Managed Care Provider Relations Manager Job Description | Salary.com. (2016). Retrieved July
19, 2016, from http://swz.salary.com/salarywizard/Managed-Care-Provider-RelationsManager-Job-Description.aspx

Nguyen, A. N., Taylor, J., & Bradley, S. (2003, August). Job Autonomy and Job Satisfaction:
New evidence. Retrieved July 21, 2016, from
http://www.lancaster.ac.uk/staff/ecasb/papers/job%20autonomy%20%20job
%20satisfaction%2030july03.pdf

U.S. Bureau of Labor Statistics. Healthcare: Millions of jobs now and in the future. (2014,
March). Retrieved July 19, 2016, from
http://www.bls.gov/careeroutlook/2014/spring/art03.pdf

What am I worth? (2016). Payscale.com. Retrieved July 20, 2016, from

http://www.payscale.com/research/US/Job=Provider_Relations_Manager/Salary