The Provider Relations Representative is responsible for assisting in the full range of provider relations and service interactions within UnitedHealth Group, including working on end-to-end provider claim and call quality, ease of use of physician portal and future service enhancements, and training and development of external provider education programs. Provider Relations Representatives assist in the design and implementation programs to build and nurture positive relationships between the health plan, providers (physician, hospital, ancillary, etc.), and practice managers. Other responsibilities include supporting those who direct and implement strategies relating to the development and management of a provider network, identify gaps in network composition and services to assist the network contracting and development staff in prioritizing contracting needs, and may also be involved in identifying and remediating operational short-falls and researching and remediating claims. In this role you will be expected to:- Apply basic knowledge of theories, practices and procedures.- Perform routine or structured work.- Respond to routine or standard requests.- Use existing procedures and facts to solve routine problems or conduct routine analyses.- Depend on others for instruction, guidance or direction.We are in search of a self-directed professional with a strong work ethic and the ability to thrive under pressure situations. If you want to work in a position that offers challenging work and a variety of problems to solve and troubleshoot, this might be the right role for you. Primary responsibilities include:* Accountable for ownership of provider claim projects in an end to end process, from initial provider contact, identification of claim payment issue, facilitation of resolution of claim payment issues and communication of outcome to provider. * Ability to educate provider on details of UHG reimbursement policies, billing requirements, etc... Understand and specializing in multiple markets with the intent to know and understand the physicians, facilities and ancillary providers and the nuances of their contracts and the related claim issues. * Interact directly with market providers and internal staff in the resolution of claim issues. * Maintain ongoing communication with providers throughout the project process. * Research claims to determine accuracy and identify root cause of any claim payment issues.* Enable team members to ensure consistent quality service to UHGs participating providers. * Resolve complex issues, support fellow CPMs, providing feedback and training as needed. * Respond to complex escalated provider written, electronic and phone contacts within current turnaround times. * Research, analyze, identify root cause and coordinate resolution of claim issues with business partners within current turnaround times* Gather information to properly analyze issues. The ability to prioritize, and multi-task effectively is required for success in this position. * Work with provider to gather information, prepare and submit claim projects (20 or more claims) to the Claims Resolution Team (CRT) when appropriate; * Ensure accurate project submission based on the identified root cause. * Monitor progress of project and provide periodic updates to provider contact. * Upon project completion by CRT, audit project results, send rebuttals as necessary. * Prepare and send project results to provider contact, Conduct final provider call to review project outcome and ensure provider satisfaction with project results. * Work collaboratively with CPM and resolution partners to resolve complex claim reimbursement issues that require additional assistance from other Departments within UHG.* Accountable for accurate documentation and routing of issues to appropriate resolution partners. Maintain daily tracking and documentation of all project activities and communications within the DCT* Complete all communications and follow up activities within established TAT's. * Support and represent CPM on conference calls and special projects as assigned. * Serve as primary point of contact for Market Service Agent (MSA), Network Service Agent (NSA) and Senior Service Agent (SSA) in resolution of claims project issues; check status of critical issues. Participates in conference calls with MSA, NSA, and SSA & NM to obtain information and improve service.* Meet or exceed all productivity and quality assurance expectations and guidelines.* Successfully completes and effectively utilize all required training. * Maintain compliance with all Federal (i.e. HIPPA), State (i.e. fee schedule disclosure laws), and local regulations and laws.* Other duties as assigned.* Excellent Customer Service skills, ability to handle irate callers, gain the callers trust, take ownership of callers issue and manage through to resolution. * Experience and/or demonstrated understanding/knowledge of physician, ancillary and facility contracting methodologies, contract loading and contract interpretation. * Experience and/or demonstrated understanding/knowledge of physician, ancillary and facility claims, including submission, coding and processing. * Five to seven years relevant experience, including three in medical claims reimbursement and minimum of two years in direct customer service. * Experience in team interactions and improvement methods/projects * Ability to understand claims system configuration and appropriate loading methodologies of complex contracts into the system. * Ability to systematically analyze problems, draw relevant conclusions and devise appropriate courses of action * Ability to interpret electronic data and apply to health care claim processing * Mandatory experience and superior skills in UHGs processes, systems, and products, including but not limited to: UNET, Cosmos, NDB, ORS, Knowledge Library, RPU2U, SOS Help, Lotus Notes, WAND, CCS View, IDRS, TDARS, EDSS * Mandatory experience and superior skills in UNET claims as follows: claim payment, history review, and complex adjustment review, manual claim calculations, review provider contract set up and selection. * Strong PC skills (Word, Excel, Access, etc) is mandatory * Clear spoken voice and solid communication skills, both verbally and written. * Proven ability to provide superior customer service * Strong ability to research, understand and communicate UHGs reimbursement policies * Ability to work independently and make sound decisions in a fast paced environment * Knowledge of medical terminology, referral and authorization practices, standard-coding methodologies (CPT, ICD-9, HCPCS and revenue) required * Proven ability to manage multiple tasks, prioritize and meet deadlines under a heavy workload. * Excellent follow up, organizational and change management skills required. * Proven problem solving skills are key to success in this role. * College degree preferred; high school diploma required
Requirements:- Undergraduate degree- 1+ years of managed care or medical insurance experience.- 1+ years experience in a claims, customer service or provider support role.- Ability to work independently and remain on task.- Good organization and planning skills.- Strong interpersonal and oral communication skills including telephone etiquette.- Ability to prioritize and meet deadlines from multi-staff members within the department.- Strong research and analytical skills.- Intermediate level of proficiency with MS Excel and Word.UnitedHealthcare, part of the UnitedHealth Group family of companies, is comprised of three specialized businesses dedicated to meeting the health care benefits needs of individuals and groups; all part of something greater, but each with a specialized focus:UnitedHealthcare Employer & Individual works with individuals, small businesses and large multi-site employers to provide innovative, affordable benefits services.UnitedHealthcare Medicare & Retirement is focused on serving Americans over the age of 50. It is the largest business dedicated to meeting the growing health and well-being needs of aging individuals in the nation, serving one in five Medicare beneficiaries through a comprehensive and diversified array of products and services through four industry-leading businesses.UnitedHealthcare Community & State provides high-quality, personalized, public-sector health care programs that help local government agencies improve health outcomes for millions of children and low-income and disabled individuals at an affordable cost.Together, were removing the barriers that keep people from receiving the kind of quality health care that makes a difference. We focus on Integrity, Compassion, Relationships, Innovation and Performance as we empower people to achieve better health and well-being.Come grow and thrive in our culture of innovation and ideas. Because there is no opportunity greater than the quest to help people live healthier lives.