Analysis Skills, Communication Skills, Content Management Systems (CMS), Customer Relations, Health Plan, Healthcare, Healthcare Customer Service, Healthcare Effectiveness Data and Information Set (HEDIS), Healthcare Providers, Identify Issues, Leadership, Marketing, Network Support, Presentation/Verbal Skills, Problem Solving Skills, Process Improvement, Project/Program Management, Relationship Management, Root Cause Analysis, Sales, Time Management, Writing Skills
Purpose:
The UPMC Health Plan is looking for someone who enjoys investigating medical claims issues, supporting providers, and build strong partnerships to fill the role of Provider Network Advocate!
The Provider Network Advocate (PNA will support the Provider Network Liaison (PNL team and will investigate issues with other ISD departments. The PNA will assist with outreach to providers to investigate operational initiatives, identify root causes and take action to resolve the issue. Investigations and outreach will include provider payment issues, configuration issues, special outreach projects and HEDIS, HCC, CDPS, MA P4P, and CMS Stars improvement initiatives. The PNA will outreach to providers related to key departmental goals, via phone, email and personal visits as requested.
This role is Hybrid and will require a minimum of 3 days per week onsite in Downtown Pittsburgh, as well as occasional travel throughout the area.
Responsibilities:
- Coordinate provider problem resolution as identified through internal reports and by the PNL team or ISD leadership.
- Identify root causes, swiftly take the needed steps to resolve the issue and ensure closed feedback loop to the PNL and provider occurs.
- Present health plan programs and tools to network providers and their office staff.
- Follow up with provider as necessary to ensure understanding.
- Document provider outreach and initiative progress in a customer relationship database in a timely manner.
- Collaborate with other Network Leaders and staff to ensure process improvement within department.
- Manage relationships with key providers within the Health Plan provider network as directed.
- Effectively manage special projects as assigned to complete in a timely manner, occasionally, the employee will need to extend hours beyond 40-hour work week.
- Bachelor's Degree in Business, Health Care, Marketing or a related field is required or equivalent experience.
- 3 years business/sales or healthcare-related experience required.
- Experience with Provider Services, Medical Claims, Customer Service, or Member Services preferred.
- Experience with claims investigation and problem analysis preferred.
- Excellent written and verbal, communication skills, as well as the ability to document organize, analyze and problem solve required.
- Ability to attend or accompany Director or PNL to various internal and external department and provider meetings.
UPMC is an Equal Opportunity Employer/Disability/Veteran
U
University of Pittsburgh Medical Center