Provider Relations Representative - Hybrid

UPMC; Pittsburgh (Allegheny County); Hybrid; USD 55,000 - 75,000; Full time

Job summary

UPMC Community Care Behavioral Health seeks a full-time Provider Relations Representative to join the Network Management team in downtown Pittsburgh. This hybrid role requires three in-office days per week with some travel to provider sites.

You will manage an assigned panel of providers and support additional caseloads as needed. You will ensure providers are informed about policies, credentialing, contracting, claims and authorizations, and understand differences among product lines.

Qualifications

• Experience in behavioral health provider relations preferred.
• Ability to navigate credentialing and contracting processes.
• Strong communication and problem-solving skills.

Responsibilities

• Build and maintain relationships with external providers across assigned caseload.
• Serve as primary contact for providers and support additional caseloads as needed.
• Ensure providers understand policies, credentialing, contracting, claims and authorization functions.
• Explain differences among product lines and provider obligations.
• Develop provider manuals and handbooks with input from staff and advisory groups.
• Create and implement actions in response to provider service calls.
• Participate in provider orientation and follow-up with assigned group.
• Distribute educational materials and ensure providers have current copies of billing handbooks.

Skills

Provider relations

Healthcare network experience

Customer service

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.