This role supports provider network performance by strengthening provider relationships, resolving complex operational issues, delivering provider education, and partnering across claims, contracting, compliance, network, and operational teams.
Jobs in this family manage provider networks that support the client base, including HCBS providers, assisted living facilities, and in-home support services. Responsibilities include provider relations activities, provider performance analysis, provider reimbursement arrangements, and credentialing activities.
Positions in this function are accountable for the full range of provider relations and service interactions within UHG, 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. Designs and implements programs to build and nurture positive relationships between the health plan, providers, and practice managers. Directs and implements strategies relating to development and management of a provider network. Identifies gaps in network composition and services to assist network contracting and development staff in prioritizing contracting needs. May also be involved in identifying and remediating operational shortfalls and researching and remediating claims.
The Senior Provider Relations Advocate serves as a strategic partner between the health plan and the provider community, driving provider satisfaction, operational excellence, education, issue resolution, and regulatory compliance. This role functions as a subject matter expert and trusted advisor for provider-facing operations, claims and payment support, provider engagement, and cross-functional collaboration.
General Job Profile- Generally, work is self-directed and not prescribed
- Works with less structured, more complex issues
- Serves as a resource to others
Job Scope and Guidelines- Assesses and interprets customer needs and requirements
- Identifies solutions to non-standard requests and problems
- Solves moderately complex problems and/or conducts moderately complex analyses
- Works with minimal guidance; seeks guidance on only the most complex tasks
- Translates concepts into practice
- Provides explanations and information to others on difficult issues
- Coaches, provides feedback, and guides others
- Acts as a resource for others with less experience
Additional Scope and Guidelines- Field and virtual meetings with providers and internal partners, supporting high-complexity, high-volume, high-spend provider groups or specialties
If you are located in AZ, you will have the flexibility to work remotely* as you take on some tough challenges.
Primary Responsibilities:- Develop provider relationships
- Resolve complex claims and operational issues
- Educate providers on policies and regulatory requirements
- Facilitate provider meetings and training
- Identify trends and process improvement opportunities
- Collaborate across claims, contracting, network, compliance, and operational teams
- Support network initiatives
- Mentor peers and serve as a resource
You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.
Required Qualifications:- 5+ years of healthcare or managed care experience
- 3+ years of provider relations or provider network experience
- Medicare and/or Medicaid experience
- Experience working directly with physician groups or hospitals
- Solid claims knowledge
- Proven advanced communication, presentation, and Microsoft Office skills
Preferred Qualifications:- Experience with Medicaid, Medicare Advantage, Dual Eligible, ALTCS, HCBS, behavioral health, hospital, facility, or ancillary providers
- Experience with provider portals, EDI, EFT/ERA, eligibility, prior authorization, training delivery, and operational analytics
Functional Competency & Description- PRV_Demonstrate Knowledge of Relevant Systems, Operations, Processes, and Trends
- Demonstrate understanding of internal claims and payment policies and procedures; systems such as CSP, FACETS, ServiceNow, Spire, and the UHC provider portal;
vendor platforms, EDI processes, and clearinghouses; provider contracting terminology and methodology; coding, billing, and reimbursement policies; policies and procedures impacting providers; fee negotiation protocols; branding, service tools, and outreach activities; industry trends, regulations, and health care reform; MS Office, PowerPoint, Excel, and relevant applications; and market trends and current events impacting the provider community
- PRV_Identify/Analyze/Resolve Provider Issues
- Gather data from claims, data warehouse, payment integrity, EDI/portal reporting, customer relations systems, and business partners
- Collaborate with colleagues and business partners to identify potential root cause of issues
- Analyze data to determine root cause, trends, patterns, outliers, and anomalies; escalate as necessary
- Coordinate stakeholder solutions and ensure provider updates are communicated within defined metrics
- Ensure provider data is accurate through audits, re-credentialing, and/or outreach
- PRV_Advocate and Communicate Provider Tools and Resources
- Provide onboarding and orientation to new providers
- Develop resources and programs to assist and educate providers, including training and FAQs
- Communicate industry and company information through newsletters, emails, outreach calls, teleconferences, conferences, and on-site meetings
- Educate providers on policies, procedures, administrative tools, and clinical tools/processes
- PRV_Support/Recruit/Retain Network Providers
- Analyze network adequacy and recruitment opportunities
- Conduct recruitment activities and communicate network outcomes
- Build and sustain effective provider relationships
- Support recruiting and retention efforts by identifying and implementing service improvement opportunities
- Solicit feedback and develop action plans; help providers improve performance under incentive contracts and accountable care strategies
Core Competencies- Provider Relationship Management; Claims Resolution; Provider Education; Escalation Management; Regulatory Compliance; Strategic Communication; Cross-Functional Collaboration; Process Improvement; Data Analysis; Coaching and Mentoring
Success Measures- Provider satisfaction, timely resolution of escalated issues, reduction of repeat provider inquiries, successful provider education efforts, operational improvements, and strong cross-functional partnership outcomes
Values Based Competencies - Employee- Integrity Value: Act Ethically - Comply with applicable laws, regulations and policies; demonstrate integrity
- Compassion Value: Focus on Customers - Identify and exceed customer expectations; improve the customer experience
- Relationships Value: Act as a Team Player - Collaborate with others; demonstrate diversity awareness; learn and develop
- Relationships Value: Communicate Effectively - Influence others; listen actively; speak and write clearly
- Innovation Value: Support Change and Innovation - Contribute innovative ideas; work effectively in a changing environment
- Performance Value: Make Fact-Based Decisions - Apply business knowledge; use sound judgement
- Performance Value: Deliver Quality Results - Drive for results; manage time effectively; produce high-quality work
*All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy
Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you'll find a far-reaching choice of benefits and incentives. The salary for this role will range from $72,800 - $130,000 annually based on full-time employment. We comply with all minimum wage laws as applicable.
