Job Description

Job Title: HCBS Provider Monitoring Specialist - Senior (Philadelphia)
Job ID: 740560
Status: Full-Time
Regular/Temporary: Regular
Hours:
Shift: Day Job
Facility: UPMC Health Plan
Department: Community HealthChoices
Location: 2709 N Broad Street, Philadelphia PA 19132

Description

Community HealthChoices (CHC) is Pennsylvania's managed care long term services and supports (LTSS) program serving seniors and individuals with physical disabilities in the Commonwealth, as well as dual-eligible individuals covered by Medicare and Medicaid.


This position supports Home and Community Based Providers (HCBS) in gaining operational efficiencies by identifying and addressing process improvement opportunities. This position also performs on-going monitoring to ensure provider compliance with both internal UPMC and governmental regulatory requirements.

Responsibilities:

 

  • Ability to explain results of findings to internal and external stakeholders
  • As requested assist with review of client documentation such as Certificate of Coverage, Summary Plan Designs and Requests for Proposals
  • Assist other departments during periods of backlog
  • Attends meetings on behalf of Management team
  • Collaborate with Product Development staff in review of proposed benefit plans ensuring ACA compliance and systematic approaches to configuration
  •  Identify areas of concern while providing optimal solutions to resolution
  • Communicate effectively and regularly with other team members, management, and applicable stakeholders
  • Complete Executive Summary management documentation as required
  • Completes adjustments and/or other inquiries generated from the data reporting and analysis area
  • Creates, maintains and completes automation process for Fee Schedule updates to MC400 claims transactional system
  • Effectively prioritize and complete all assigned tasks
  • Ensures controls are in place and are monitored to meet compliance and regulatory standards as well as UPMC organizational policies
  • Generate accurate and detailed reports for effective monitoring, trending, and analysis
  • Identify appropriate resources and support needed to facilitate decisions to achieve optimal outcomes
  • Identify areas of concern or provider deficiencies through data analysis and propose solutions based on findings and established protocols.
  • Interface with customers by telephone, correspondence, and or in person to answer inquiries and resolve concerns/issues
  • Maintains employee/insured confidentiality
  • Manages special projects as assigned by Management team; develops/maintains project plans, as needed
  • Manages, updates, and maintains source data dictionaries as they relate to processes
  • Meets deadlines and turnaround times set by Management staff and Compliance Regulators which may, at times, require an employee to work extended hours until completion of project
  • Openly participate in team meetings, provide ideas and suggestions to ensure client satisfaction, and promote teamwork
  • Participates in training programs when available/as requested
  • Provide oversight to Compliance regulations and publications for required system updates throughout all lines of business. Attends Compliance meetings as scheduled.
  • Provide quality and accurate outcomes that meet expected deadlines/turnaround times
  • Successfully manage assigned projects and initiatives

 

Qualifications

  • Bachelors Degree in related field or equivalent work experience
  • 5 years general business experience

    Licensure, Certifications, and Clearances:
    UPMC is an equal opportunity employer. Minority/Females/Veterans/Individuals with Disabilities

Salary Range: $26.64 to $44.88

Union Position: No

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