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Provider Monitoring Specialist Senior

  • Job ID: 347451369
  • Status: Full-Time
  • Regular/Temporary: Regular
  • Hours: 7:30am-4pm
  • Shift: Day Job
  • Facility: UPMC Health Plan
  • Department: Community HealthChoices
  • Location: Work From Home
  • Union Position: No
  • Salary Range: $30.12 to $46.71 / hour

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 who are covered by Medicare and Medicaid. 

This position will be work from home but requires travel into the community. Strong preference for candidates that reside in Reading, Lancaster, Allentown, and Wilkes Barre. 


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:

 

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

 

Qualifications

Qualifications:

  • Bachelors Degree and/or equivalent education or work experience.
  • 5 years of general business experience required

Preferences:

  • Strong Excel skills 
  • Strong written and oral communication skills
  • Strong preference for candidates that reside in Reading, Lancaster, Allentown, and Wilkes Barre. 

Licensure, Certifications, and Clearances:

  • Driver's License
  • Act 34

  • UPMC is an Equal Opportunity Employer/Disability/Veteran

Total Rewards

More than just competitive pay and benefits, UPMC’s Total Rewards package cares for you in all areas of life — because we believe that you’re at your best when receiving the support you need: professional, personal, financial, and more.

Our Values

At UPMC, we’re driven by shared values that guide our work and keep us accountable to one another. Our Values of Quality & Safety, Dignity & Respect, Caring & Listening, Responsibility & Integrity, Excellence & Innovation play a vital role in creating a cohesive, positive experience for our employees, patients, health plan members, and community. Ready to join us? Apply today.

   Current UPMC employees must apply in HR Direct