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Home and Community Based Sr Provider Relations Advocate - Rhode Island

UnitedHealth Group

Warwick, RI
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Job Details

734831 Home and Community Based Sr Provider Relations Advocate Rhode Island

Home and Community Based Sr Provider Relations Advocate - Rhode Island (734831)

Position Description

Expanding access to affordable, high quality health care starts here. This is where some of the most innovative ideas in health care are created every day. This is where bold people with big ideas are writing the next chapter in health care. This is the place to do your life's best work.(sm)

This role is responsible for 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 provider portal(s) and future service enhancements, and training & development of external provider education programs. Senior Provider Relations Advocates design and implement programs to build and nurture positive relationships between the health plan, providers - including but not limited to home and community based & preventive service providers, physician, hospital, ancillary, etc., and practice / agency managers. Responsibilities also include directing and implementing strategies relating to the development and management of a provider network, identifying 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.

Under the direction of the Director of Community & State Network Programs for RI, this role ensures that RI Community Plan maintains an adequate network of Home and Community Based Service (HCBS) Providers / Preventive Service Providers including but not limited to Adult Day Care, Personal Emergency Response, Home Modification, Homemaker, Personal Care Attendant and additional providers as appropriate.   


Primary Responsibilities:

  • Assess and interpret customer needs and requirements
  • Identify solutions to non-standard requests and problems

  • Solve moderately complex problems and/or conduct moderately complex analyses

  • Work with minimal guidance; seek guidance on only the most complex tasks

  • Translate concepts into practice
  • Provide explanations and information to others on difficult issues

  • Coach, provide feedback, and guide others

  • Act as a resource for others with less experience

Core Responsibilities: 


To support Community & State in six major areas of concentration as the HCBS & Preventive Services Provider Point of Contact:

  • HCBS / Preventive Service Provider Contracting Support

    • Distribution and monitoring of initial provider application, credentialing documents ensuring receipt prior to contract execution

    • Maintain credentialing documentation ensure recredentialing (and monthly ongoing monitoring) is done in a timely manner and tracked in the database

    • Enter & Maintain HCBS / Preventive Service Provider and contracting databases (creation, execution, loading, audit)

    • Creates & Maintains state level policy & procedures for HCBS / Preventive Service network

    • Creates reports / dashboards (re: network, geo - access, etc.)

    • Work with Clinical Care Teams to develop Single Case Agreements with Providers as needed

  • HCBS / Preventive Service Provider Quality Support

    • Conduct Site visits to ensure that facilities are clean and safe for member access (for Adult days & others as required)

    • Validate that the Adult Day Care facilities are certified by the State (RI)

    • Act as a liaison between Health Services outreach teams and HCBS / Preventive Service agencies

    • Alert Plan when inappropriate or unethical behavior is encountered

    • Identify, facilitate, resolve Provider Demographic challenges / issues (outdated data, provider turnover, etc.)

  • Membership
    • Act as a liaison between marketing and outreach teams and HCBS / Preventive Service agencies

    • Support and collaborate to promote events

    • Act as an ambassador to promote UnitedHealthcare to encourage agencies to recommend our Plan to their patients

  • HCBS / Preventive Service Provider Agency Performance

    • Participate in analysis of network with regards to referrals, case - mix and rates

    • Share referral data and results with providers

    • Facilitate discussions between UHC C&S Clinical Team and agency for areas of concern

  • Operational Efficiency
    • Work with UHC Performance Excellence Teams to focus on operational objectives such as including improvements in:   % EDI / ERA/ EFT, % Claims Pending / Denied, etc.

    • Train agency staff on provider portal tools & resources

    • Review early warning reports for claims issues and assist with identification & resolution of root causes

    • Personally reinforce all administrative changes and updates in periodic face-to-face visits

  • HCBS / Preventive Service Provider Education & Engagement

    • Provider Liaison - Provider welcoming, education and onboarding, navigating UHC & online tools, pertinent info on billing, policy, ongoing engagement & relationship with providers. Understanding HCBS Providers & their unique needs

    • Support & assist in resolving Provider issues related to claims submission and processing, authorizations - engaging appropriate operations staff, etc.

    • Development, maintenance and compliance of the provider manual, provider newsletters and provider education and quick reference materials - working with UHC’s HCBS National Complex care team and communications to author & update

    • Communicate regulatory directed initiatives

    • Update providers of UnitedHealth Group operational and organization changes

    • Promote new initiatives and innovations, i.e. electronic medical records, etc.

    • Work with Optum staff (HCBS / HBTS provider overlaps)

    • Implement and support administrative simplification initiatives

    • Support & Participate in Town Hall Mtgs

    • Supports the development, HCBS Provider Survey (beginning for 2018)


Required Qualifications:

  • Rhode Island on site presence
  • Undergraduate degree or equivalent work experience

  • 4+ years of provider relations and / or provider network experience

  • Intermediate level of proficiency in claims processing and issue resolution

  • 3+ years of experience with Medicare and Medicaid regulations

  • Intermediate level of proficiency with Outlook, MS Word, Excel, PowerPoint, Access and contract database tools & technology

  • Strong leadership and collaboration skills as it is necessary to work cross functionally and influence other teams, leadership and internal business partners

Preferred Qualifications:
  • Exceptional presentation, written and verbal communication skills

  • Ability to work independently as well as within a team and to remain on task

  • Excellent organization and planning skills, including the ability to communicate effectively with various levels of leadership

  • Ability to prioritize and meet deadlines from multi - staff members within the department

  • Strong knowledge of business processes that impact contract loading and auditing

  • Familiarity with the Rhode Island Market

Careers at UnitedHealthcare Community & State. Challenge brings out the best in us. It also attracts the best. That's why you'll find some of the most amazingly talented people in health care here. We serve the health care needs of low income adults and children with debilitating illnesses such as cardiovascular disease, diabetes, HIV/AIDS and high-risk pregnancy. Our holistic, outcomes-based approach considers social, behavioral, economic, physical and environmental factors. Join us. Work with proactive health care, community and government partners to heal health care and create positive change for those who need it most. This is the place to do your life's best work.SM



Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.

UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.


Job Keywords: provider relations, provider network, claims processing and issue resolution, Medicare and Medicaid regulations, Warwick, RI, Rhode Island


Job Details

  • Contest Number734831
  • Job TitleHome and Community Based Sr Provider Relations Advocate - Rhode Island
  • Job FamilyNetwork Management
  • Business SegmentCommunity and State

Job Location Information

  • Warwick, RI
    United States
    North America

Additional Job Detail Information

  • Employee StatusRegular
  • ScheduleFull-time
  • Job LevelIndividual Contributor
  • ShiftDay Job
  • TravelYes, 25 % of the Time
  • Telecommuter PositionNo
  • Overtime StatusExempt

UnitedHealth Group is the most diversified health care company in the United States and a leader worldwide in helping people live healthier lives and helping to make the health system work better for everyone.

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