Provider Relations Representative - Hybrid

UPMC•Pittsburgh, PA

8d•Hybrid

About The Position

UPMC Community Care Behavioral Health is hiring a full-time Provider Relations Representative for its Network Management team. This hybrid position is based in downtown Pittsburgh’s U.S. Steel Tower, with three in-office days per week and occasional travel to provider sites. The representative builds and maintains relationships with external providers, serves as the primary contact for an assigned caseload, and supports additional caseloads as needed. The role ensures providers understand Community Care’s policies and procedures, credentialing requirements, contracting processes, and claims and authorization functions. It also requires understanding how commercial, Medical Assistance, and other product lines differ and how those differences affect provider obligations. The representative helps ensure providers meet enrolled consumers’ clinical needs while complying with service delivery standards, supports provider education and service resolution, and coordinates with colleagues on network quality and operational needs.

Requirements

Bachelor of Arts or Bachelor of Science degree in healthcare, human services, or a related field.
Two years of experience working in a complex organizational environment.
Two years of experience in a healthcare or managed care environment.
Excellent written and oral communication skills.
Ability to clearly and consistently articulate standards of care and the specifics of various provider agreements.
Independent problem-solving skills, including the ability to address issues in a timely and accurate manner.
Knowledge of public and private behavioral health care delivery systems.
Valid Pennsylvania driver’s license and reliable car.

Nice To Haves

Experience as a provider of behavioral health services and/or knowledge of the behavioral health provider system is strongly preferred.

Responsibilities

Ensure providers meet the clinical needs of enrolled consumers while complying with service delivery standards.
Share responsibility with department personnel for answering the provider line.
Establish and maintain effective working relationships with an assigned panel of providers.
Work with the Director, Provider Relations, and other staff to develop provider manuals and handbooks, incorporating provider input and advice from designated advisory groups.
Develop and implement an Action Plan in response to each provider service call.
Participate in developing and delivering provider orientation and provide follow-up as needed for the assigned group.
Work with colleagues to develop provider newsletters and other educational materials.
Ensure assigned providers have current educational materials, including the billing handbook and provider manual; interpret materials consistently and accurately and identify and propose solutions to problems.
Work with Provider Relations staff to ensure corrective action plans are implemented and result in complete problem resolution.
Complete assignments within deadlines at least 95% of the time.
Meet or exceed quarterly goals for provider service meetings.
Balance external provider service responsibilities with in-office responsibilities.
Coordinate service schedules with other Service Representatives to ensure adequate and consistent phone coverage.
Implement network quality indicators and work with providers as needed to ensure understanding and compliance.
Manage the supplemental service enrollment process for the assigned provider panel.
Understand and communicate the authorization process and Community Care procedures for delivering authorizations to providers.
Travel to provider sites as needed; maintain a valid Pennsylvania driver’s license and reliable car.