Provider Relations Representative, Sr. jobs in Johnstown, PA

UPMC Community Care Behavioral Health is seeking a full-time Provider Relations Representative to support the Network Management Department in Somerset, PA!

The Provider Relations Representative will work daylight hours, Monday through Friday, in a hybrid work structure! This role will primarily work from home, but will have weekly office time during the first few weeks of training. Additionally, there may be some occasional required office visits for meetings and/or other departmental needs.

The Provider Relations Representative will initiate and develop working relationships with external providers, managing a primary caseload of assigned providers, for whom they are the principal point of contact, and covering other caseloads occasionally as circumstances require. This role ensures that providers are fully educated as to appropriate policies and procedures for conducting business with Community Care, and also presents 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. 

The ideal candidate for this position will be well-versed in the differences between commercial, Medical Assistance, and all other products, with an emphasis on differences in the providers' obligations for each. Behavioral health services experience is preferred, as well!

Responsibilities:

• Ensure 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 the development and delivery of provider orientation, and follow-up as needed with assigned group.
• Work with colleagues on the development of provider newsletters and other educational materials.
• Ensure that assigned providers have current copies of all relevant educational materials, including the billing handbook and provider manual.
  • 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 a member of the Provider Relations staff, ensuring that corrective action plans are implemented and result in complete problem resolution.
• Responsive to deadlines, completing 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 the use of quality indicators for use within the network, including working with providers as necessary to ensure full understanding and compliance.
• Manage supplemental service enrollment process for his/her designated panel of providers.
• Understand and communicate the details of the authorization process and Community Care's procedures for delivering the authorizations to providers.