Provider Relations Representative

Upper Peninsula Health Plan•Marquette, MI

6d•$22

About The Position

This position handles provider relations with practitioners, providers, and facilities for the Upper Peninsula Managed Care (UPMC) network. This is accomplished through integration of activities with the UPMC claims, customer service, credentialing, information systems, and clinical services departments; provider offices; and the commercial companies that utilize the UPMC network.

Requirements

Associate degree in business, office information services, health information processing, computer information systems, or related field
One (1) to two (2) years of experience in health-care operations, provider relations, or customer service
Working knowledge of MS Office (Word, Excel, and PowerPoint)
Excellent human relation and oral/written communication
Excellent organizational and prioritization abilities with attention to detail

Nice To Haves

Bachelor’s degree in communications, public relations, business administration, or related field
Three (3) to four (4) years of customer relations experience in a health-care setting and/or a business background in health care; prior contracting experience

Responsibilities

Follows established Upper Peninsula Health Plan (UPHP) policies and procedures, objectives, safety standards, and sensitivity to confidential information.
Assists practitioners and providers wishing to contract with UPHP and coordinates the contracting process and ensures all steps of the process are completed timely.
Provides general support to providers seeking assistance through phone, email, mail, fax, etc.
Acts as liaison for provider offices and commercial companies utilizing the UPMC network. This includes handling identified system claims issues, reimbursement issues, and provider file maintenance; answers inquiries from providers about commercial companies; and investigates and resolves discrepancies associated with provider file information with the commercial companies.
Assists commercial companies under network access agreements and new companies inquiring about network access and contracting agreements; responsible for facilitating provider information updates to commercial companies.
Responsible for the execution, reporting, and file maintenance of site visit surveys.
Supports processes to ensure network provider data is accurate and inputs provider and group contract information into the CACTUS credentialing system; works with configuration staff to ensure accurate provider data is loaded into the Claims Processing System.
Provides support to other departments through verification of provider data, problem solving with provider offices, assisting and finalizing provider communication documents, and responding to access and availability provider related concerns and potential leads.
Assists in the planning and implementation of provider events, including, but not limited to provider in-service and educational webinars.
Assists in compliance reporting to Michigan Department of Health and Human Services (MDHHS) related to contracting, network adequacy and access, provider directory data, and provider network related policies.
Assists in ensuring compliance with State, Federal, and accrediting agencies’ network adequacy standards. Augments and modifies the provider network as needed in order to comply with applicable network adequacy standards, including those standards set forth by the Centers for Medicare and Medicaid Services (CMS).
Orients new and existing providers to the health plan; sends copies of provider material (i.e., provider newsletters, formulary) to providers.
Demonstrates knowledge of National Committee for Quality Assurance (NCQA) standards for contracting, site visits, access and availability and supports NCQA submissions.
Maintains confidentiality of client data.
Performs other related duties as assigned or requested.