Healthcare Provider Relations Specialist

Job Summary

The Healthcare Provider Relations Specialist is responsible for developing, optimizing, and managing a national healthcare provider network that supports direct billing services and exceptional user experience. The role combines provider network development, contract negotiation, provider relations, utilization management, fraud detection, performance analytics, compliance oversight, and operational support.

Why Join GuardMe?

At GuardMe International Insurance, we recognize that our people are our greatest asset. We are committed to fostering a collaborative, innovative, and supportive workplace where ideas are encouraged and contributions are valued.

As part of our award-winning team, you'll have the opportunity to make a meaningful impact while working alongside experienced professionals who are passionate about supporting students and educational institutions around the world.

Responsibilities:

Provider Network Development & Strategy

• Expand and optimize the provider network across Canada, focusing on clinics, hospitals, specialists, laboratories, diagnostic facilities, and other healthcare providers.
• Identify geographic coverage gaps through utilization and access analysis and develop action plans to improve network adequacy.
• Support the development of network strategies that improve access, quality of care, and cost effectiveness.

Provider Relations & Engagement

• Serve as the primary point of contact for network providers.
• Responsible for managing all communication with prospective and existing providers in a timely and professional manner documented through appropriate business software.
• Build and maintain strong provider relationships through regular meetings and site visits.
• Create and manage provider performance reviews according to approved metrics, on a quarterly basis.
• Support provider onboarding, education, and training regarding direct billing processes and requirements.

Contract Negotiation & Direct Billing Management

• Negotiate, implement, and manage provider agreements according to business policies, to include reimbursement schedules, fee structures, and direct billing arrangements.
• Review fee schedules and assess financial impacts on claims costs and loss ratios.
• Proactively monitor invoice submission timeliness, billing accuracy, and adherence to provider agreements.

Network Performance & Analytics

• Develop and/or work with IT to create dashboards in the software and reports to support decision making and identify improvement opportunities.
• Analyze provider utilization, billing trends, cost drivers, insured access patterns, and provider network performance metrics using business software.

• Provide recommendations to leadership regarding network optimization and cost containment initiatives.

Fraud Detection, Audit & Risk Management

• Monitor billing patterns and utilization trends to identify anomalies, duplicate billing, excessive utilization, or other potential fraud indicators.
• Create and manage a process to conduct provider audits while supporting investigations in collaboration with Claims, Compliance, IT, and Legal teams.
• Recommend corrective actions and process improvements to strengthen claim integrity and provider accountability.

Quality Assurance

• Ensure provider agreements and network operations comply with applicable regulations, privacy requirements, and organizational policies.
• Maintain accurate provider records, documentation, and reporting.
• Participate in quality assurance initiatives and continuous improvement activities.

Cross-Functional Collaboration

• Partner with Claims, Operations, Customer Care, Compliance, Finance, Marketing, Sales, and external stakeholders to support organizational objectives.
• Assist with provider-related escalations and operational issues during peak periods.

Knowledge & Compliance

• Read, acknowledge, and comply with all policies and procedures of the organization.
• Attend privacy and security training during onboarding and annually thereafter.
• Immediately notify the Privacy Office of any incident or potential incident involving unauthorized access, use, copying, alteration, or disclosure of personal information.
• Work collaboratively with the Privacy Office to gather information, implement corrective actions, and submit privacy incident reports as necessary.
• Comply with all business policies and procedures, including annual privacy and security training.
• Immediately report any potential or actual privacy or security incidents to the Privacy Office.

Additional Duties

This job description outlines the primary responsibilities and requirements for this role. However, duties, responsibilities, and activities may evolve based on organizational needs, strategic priorities, and emerging opportunities. The Healthcare Provider Relations Specialist is expected to demonstrate flexibility and adaptability in response to changing business requirements while maintaining alignment with GuardMe’s purpose, values, and ethical standards.

Education & Experience

• College diploma or bachelor's degree in a relevant field such as Healthcare Administration, Business Administration, or Health Sciences, or significant related experience demonstrating equivalent knowledge and capabilities.
• Minimum 5 years of experience in healthcare network management, provider relations, claims administration, or a related healthcare environment.
• Experience negotiating provider agreements and direct billing arrangements.

Skills & Competencies

• Strong understanding of healthcare operations, medical billing practices, provider networks, and healthcare regulations.
• Provider relationship management and stakeholder engagement expertise.
• Contract negotiation and financial analysis skills.
• Experience with utilization management, reporting, and network analytics.
• Knowledge of fraud detection, auditing, and risk mitigation practices.
• Strong communication, presentation, and problem-solving skills.
• Advanced MS Excel proficiency, as well as advanced proficiency in Word, Outlook, PPT, Teams, etc.
• Ability to manage multiple priorities and work effectively in a fast-paced environment.
• Ability to communicate in French language is an asset

This job description was developed with the assistance of AI and reviewed by Human Resources to ensure accuracy, relevance, and alignment with organizational needs.

How to Apply

Please include a cover letter with details of your relevant experience and why you feel you would be a great fit for this opportunity.

We thank all applicants for their interest; however, only those selected for an interview will be contacted.

GuardMe is an equal opportunity employer and welcomes applications from all qualified individuals. Accommodation will be provided upon request throughout the recruitment process.

About Us

GuardMe is a Canadian, independent, family-owned provider of student health insurance, wellness support, and partner-focused services for educational institutions, students, and partners across Canada and around the world.

With nearly 30 years of experience, we work with universities, colleges, language schools, school boards, and institutional partners to support student health, wellness, safety, and access to care. Our purpose is to help protect students throughout their academic journey through responsive service, practical solutions, and support when it matters most.

Our values guide how we work, collaborate, and respond to the evolving needs of students and the institutions we serve. As we continue to grow, we remain committed to building trusted partnerships, supporting student success, and creating positive outcomes for the communities we support.

The Perks

• Commitment to your growth and professional development
• Competitive compensation package
• Comprehensive health and dental benefits
• Be a part of a company that is making a difference