UPMC Community Care Behavioral Health is hiring a full-time Provider Relations Representative to support the Network Management team. This position follows a hybrid schedule, requiring in-office presence a few days per week. Candidates may work from any of the following office locations: Dubois, Moosic, or Clearfield. Occasional travel may be required, though this will be rare.

This position will initiate and develop working relationships with external providers. They will manage the primary caseload of assigned providers for whom he/she is the principal point of contact, and cover other caseloads from time-to-time as circumstances require. Assure that the provider is fully educated as to appropriate policies and procedures for conducting business with Community Care. Present comprehensive knowledge of the authorizations and claims functions, credentialing requirements, the application and contracting process, and other topics of general and specific interest to the provider. Adequately, be well versed in the differences between the commercial, Medical Assistance and all other products, with an emphasis on differences in the providers’ obligations for each.

Responsibilities:
 

• Assure that providers meet the clinical needs of enrolled consumers while continuing to comply with service delivery standards.
• Share responsibilities with other department personnel for answering the provider line.
• Establish excellent working relationships with a defined panel of providers.
• Work with the Director, Provider Relations and other staff as appropriate to develop the provider manuals and handbooks; this process will involve provider input as well as advice from appropriately designated advisory groups.
• Develop and implement an Action Plan in response to each provider service call.
• Participate in development and delivery of provider orientation and for follow-up as needed with assigned group.
• Work with colleagues on development of provider newsletter and other educational materials.
• Assure that assigned providers have current copies of all relevant educational materials, including the billing handbook and provider manual; is responsible for accurate interpretation of materials to providers in a consistent fashion and for identifying and proposing solutions to problems as they arise.
• Work as member of the Provider Relations staff, ensure that corrective action plans are implemented and result in complete problem resolution.
• Responsive to deadlines; complete assignments within deadlines at least 95% of the time.
• Meet or exceed specified goals for the number of provider service meetings on a quarterly basis.
• Balance time and effort spent on external provider servicing with in-office responsibilities.
• Coordinate service schedule with other Service Reps to ensure adequate and consistent phone coverage.
• Implement use of quality indicators for use within the network, including work with providers as necessary to assure full understanding and compliance.
• Manage supplemental service enrollment process for his/her designated panel of providers.
• Understand and communicates the details of the authorization process and Community Care’s procedures for delivering the authorizations to providers.