Provider Relations Representative - Hybrid

Pittsburgh Tomorrow; Pittsburgh (Allegheny County); Hybrid; USD 45,000 - 65,000; Full time

Job summary

UPMC Community Care Behavioral Health is seeking a full-time Provider Relations Representative for the Network Management team in downtown Pittsburgh’s U.S. Steel Tower.

This hybrid role includes three in-office days per week with occasional travel to provider sites. The ideal candidate brings behavioral health experience and a commitment to high-quality care across the provider network, serving as the primary contact for an assigned caseload and supporting credentialing, contracts, and claims

Qualifications

• BA/BS in healthcare, human services or related field.
• 2 years of experience in a complex organizational environment.
• 2 years of experience in healthcare or managed care environment.
• Experience with behavioral health services or knowledge of the behavioral health provider system preferred.
• Excellent written and oral communication skills.
• Ability to clearly articulate standards of care and provider agreements.
• Independent problem solving with timely issue resolution.
• Knowledge of public and private delivery systems in behavioral health care.

Responsibilities

• Ensure providers meet clinical needs while complying with service delivery standards.
• Answer provider line and support the panel as assigned.
• Develop and maintain relationships with a defined panel of providers.
• Assist in developing provider manuals and handbooks with input from advisory groups.
• Develop and implement action plans in response to provider service calls.
• Support provider orientation and follow-up with assigned groups.
• Contribute to provider newsletters and educational materials.
• Distribute up-to-date billing handbooks and provider manuals to providers.

Skills

Excellent written and oral comms

Independent problem solving

Behavioral health delivery systems

Education

BA/BS in healthcare or related field

Job description

UPMC Community Care Behavioral Health is seeking a full-time Provider Relations Representative to join the Network Management team. This hybrid position is based in downtown Pittsburgh’s U.S. Steel Tower and includes three in-office days per week, with occasional travel to provider sites. The ideal candidate will bring prior behavioral health experience and a strong commitment to supporting high quality care across the provider network. In this role, the Provider Relations Representative will build and maintain strong working relationships with external providers, serving as the primary point of contact for an assigned caseload and offering support to additional caseloads as needed. The representative will ensure providers are well informed about Community Care’s policies, procedures, credentialing requirements, contracting processes, and claims and authorization functions. They will also demonstrate a solid understanding of differences among commercial, Medical Assistance, and other product lines, with attention to how these variations affect provider obligations.

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.
• Valid PA drivers license and reliable car.

Qualifications

• B.A or B.S. degree in a healthcare, human services or related field.
• 2 years of experience working in a complex organizational environment.
• 2 years of experience in healthcare or managed care environment.
• Experience as a provider of behavioral health services and/or knowledge of behavioral health provider system strongly preferred.
• Excellent written and oral communication skills.
• Must clearly and consistently articulate standards of care and specifics of the various provider agreements.
• Independent problem-solving skills, including the ability to address issues in a timely and accurate manner.
• Knowledge of public and private delivery systems in behavioral health care.

Licensure, Certifications, and Clearances

UPMC is an Equal Opportunity Employer/Disability/Veteran