Provider Advocate, Home and Community Based Services - Remote in Idaho id-19638
Job Description
The HCBS Provider Advocate is responsible for working on end-to-end HCBS provider claims, ease of referral to Providers to use UnitedHealthcare Link Self Help tool, training and development of external provider education programs. HCBS Provider Advocates design and implement programs to build and nurture positive relationships between the health plan, providers (Home and Community Base services Providers, Health Homes, State Designated Entity and other atypical service providers). Responsibilities also include directing and implementing strategies relating to the development and management of a HCBS provider network, identifying gaps in network composition and services to assist the network contracting, network adequacy and in identifying and remediating operational short-falls and researching and remediating claims.
This is a fast-paced working environment that requires the ability to multitask with attention to detail and excellent organizational skills.
This is an Idaho-based role, and you will have the flexibility to work remotely* as you take on this challenging and rewarding work.
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Primary Responsibilities:
- Serve as the primary contact for the health plan to our contracted and non-contracted HCBS providers managed by the health plan to resolve all provider servicing issues including claims, authorization, copies of executed contracts, provider communication such as notices for Wage Parity, Minimum Wage compliance
- Serve as main point of contact for providers and strategically build relationships to resolve claims, prior and contract related issues managing a portfolio of accounts of HCBS providers to ensure a trusting relationship are developed and issues related to claims, prior authorization, and any other issues identified by the Providers or our internal leaders
- Serve as the key point of contact for the CEAP claims pended health home project and work collaboratively with Claims SME) to review claims parked in CP 10 by focusing on the highest denial volumes by providers. Communicate back to the Health Plan contractor regarding claim denial reason and system related error they are responsible to get fixed through submission of Core tickets and claims project
- Work closely with our claims Subject Matter Experts (SME) like the FAST and CPM team to complete sample audit of claims to identify root cause issues and address any related questions
- Conduct frequent review in Impact tool to get status update notifications on FAST cases previously submitted and develop a tracking document to monitor all open cases
- Communicate FAST ticket results to the providers within 48 hours of receiving the notification either via email or through the review process in Impact
- Monitor the Provider Advocate mailbox daily and serve as the main point of contact to answer questions related to claims and other inquiries submitted by the HCBS Providers for all atypical services managed by the health plan
- Escalate appropriate claims denial trend issues to the COPA team for immediate resolution to reduce regulatory complaint filing by providers
- Use pertinent data and facts to identify and solve a range of problems within area of expertise
- Schedule and Facilitate bi-weekly claims denial trend meeting with New Day team based on provider complaint and communication received via the mailbox or through other modes of communication
- Manage the HCBS database to ensure accuracy and non-contracted populated providers are termed from the database. Populate new contacted providers in the database for CDPAP, Adult Day, SDE's Health Homes etc. and serve as the primary contact with HCBS leader. Add new providers to the HCBS database
- Work closely with the LTSS team around prior authorization issues for all HCBS providers to ensure full payment for billed services are rendered
- Work closely with the Clinical Practice Consultants to resolve gaps identified by providers which impact provider network agreements, provider satisfaction and provider burden
- Work with manager to resolve gaps identified by providers with Provider Call center to ensure provider claims questions are being appropriately reviewed and addressed
- Complete Single Case Agreement for non-participating provider for HCBS services, Personal Care and Private Duty Nursing is out of Scope)
- Provider Complaints related to Single Case AgreementProvider Advocate will be responsible to request a copy of the Provider's SCA (Providers must bill claims with Single Case Agreement
- Maintain and manage all aspects of the Single Case Agreement (SCA) for nonparticipating providers
- Demonstrate a high level of autonomy by prioritizing and organizing your own work to meet deliverables deadlines
- Provide explanations and information to others on topics within area of expertise
- Perform outreach and education to providers on policies and procedures to maximize the mutual benefit of a contractual relationship
- Work in partnership with the credentialing team to upload and review credentialing application for new providers
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:
- 2+ years of provider relations and/or provider network experience, preferably HCBS
- Intermediate level of proficiency in claims processing and issue resolution
- Intermediate knowledge of Medicare and Medicaid guidelines
- Proficiency with MS Word and Excel
- Proven good organization and planning skills
- Willing or ability to travel 25%
- Resident of Idaho
Preferred Qualifications:
- Provider facing experience
- Knowledgeable about healthcare and managed care / health plans
- MS Access and PowerPoint
- Proven exceptional presentation, written and verbal communication skills
- Demonstrated ability to work independently and remain on task
- Demonstrated ability to prioritize and meet deadlines from multi-staff members within the department
*All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy
The salary range for this role is $59,500 to $116,600 annually based on full-time employment. Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. UnitedHealth Group complies with all minimum wage laws as applicable. In addition to your salary, UnitedHealth Group offers 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 UnitedHealth Group, you'll find a far-reaching choice of benefits and incentives.
At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission.
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.
