Description

The Staff Development Specialist, Provider Services will assist with the development and training of staff byproviding guidance, interpretation and education on eligibility levels, benefit design, claim interpretation, and various customer related inquiries. Responsible for creating and maintaining department reference materials, assisting with developing and presenting staff training, and acting as a mentor for new staff. Responsible for identifying and tracking trends to improve customer satisfaction, making suggestions for resolutions, and identifying educational and training needs for staff.

This position is 90% remote. Some travel to the office will be required. (privilege eligibility is subject to continued achievement of business goals and on-site department needs).

Responsibilities:

• Analyze and summarize special projects utilizing Microsoft Excel.
• Trend provider issues, recognize and identify issues that could substantially negatively impact UPMCHealth Plan, its participating providers, and members.
• Quality customer service includes, but is not limited to, responding to customer requests and inquiries in a timely and accurate manner in keeping with Health Plan Policies and Procedures, Department of PublicWelfare (DPW) laws and standards, Department of Insurance (DOI) laws and standards, Department of Health (DOH) laws and standards, Department of Health and Human Services (DHHS), Health CareFinancing Administration (HCFA), and National Committee for Quality Assurance (NCQA) standards.
• Identify and report any training issues to other departments during periods of backlog, including but not limited to, claims processing.
• Actively pursue open cutlog inquiries and resolve them within the designated time standards.
• Support cross-functional team members to meet or exceed designated production and quality standards.
• Quality customer service should be applied to all customers, including all Health Plan members and potential members, all Health Plan providers and potential providers, all Health Plan and Health System employees, all Health Plan and Health System vendors, and all government and other oversight organization staff.
• Coordinate, perform and monitor provider outreach as designated by management.
• Quality customer service will be measured by, but not limited to, the number of complaints from a customer (with a goal of zero) and by the number of second requests for information or response received(with a goal of zero.
• Develop and maintain department reference materials
• Complete adjustments or other inquiries that are generated from the data reporting and analysis areas.
• Respond to web messages and claim adjustment requests within time guidelines.
• Identify individual and department training needs, and develop and present training as needed.
• Provide communication to team members related to processing and procedure changes
• Communicate with providers as necessary to problem solve.
• Escalate issues and concerns in a timely fashion.
• Communicate with other departments to resolve issues.
• Support call center when necessary. Must maintain or exceed production and quality standards for call service level and/ or claims processing. Call quality: 99% production 65 calls per day. Claims quality and production based on department production and quality standards.
• Act as a mentor to new team members as well as existing staff.
• Take escalated calls and perform appropriate research and follow up
• Interface with other departments and identify adjustments required as a result of updated provider files, benefits, or eligibility information.
• Recommend solutions to existing issues. Actively participate in departmental meetings, offer suggestions and resolutions related to current issues. Performs in accordance with system-wide competencies/behaviors.

Qualifications

• High school graduate or equivalent, college degree preferred
• 2 years claims processing and/or call center experience with at least 1 year in a healthcare setting.
• Competent in claims process operating system
• Excellent knowledge of UPMC's Health Plan internal department functions
• Excellent knowledge of medical terminology, ICD-9, ICD-10 and CPT coding required
• Thorough knowledge of a minimum of two cross functional areas, including but not limited to Commercial,Medicare, Medicaid, Evolent, Ancillary, and/or claims processing
• Thorough knowledge of claims processing including adjustments and negative balances
• Thorough knowledge in MS Office and PC skills required;
• Able to demonstrate organizational, analytical, interpersonal, and communication skills;
• Ability to prioritize and perform multiple tasks while maintaining designated production and quality standards.

Licensure, Certifications, and Clearances:

UPMC is an Equal Opportunity Employer/Disability/Veteran

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