Provider Relations Representative at Upper Peninsula Health Plan

Marquette, Michigan, United States -

Full Time

Start Date

Immediate

Expiry Date

25 Jun, 26

Salary

22.46

Posted On

27 Mar, 26

Experience

0 year(s) or above

Remote Job

Yes

Telecommute

Yes

Sponsor Visa

Skills

Provider Relations, Contracting, Claims Issues, Reimbursement Issues, File Maintenance, Data Accuracy, Credentialing System, Claims Processing System, Compliance Reporting, Network Adequacy, Provider Directory Data, NCQA Standards, MS Office, Communication, Organization, Prioritization

Industry

Insurance

Description

DATE: March 26, 2026 POSITION: Provider Relations Representative DEPARTMENT: Operations-Provider Relations BASE RATE: $22.46 per hour, with potential for additional compensation based on qualifications POSITION SUMMARY: This position handles provider relations with practitioners, providers, and facilities for the Upper Peninsula Managed Care (UPMC) network. This is accomplished through integration of activities with the UPMC claims, customer service, credentialing, information systems, and clinical services departments; provider offices; and the commercial companies that utilize the UPMC network. ESSENTIAL DUTIES AND RESPONSIBILITIES: 1. Follows established Upper Peninsula Health Plan (UPHP) policies and procedures, objectives, safety standards, and sensitivity to confidential information. 2. Assists practitioners and providers wishing to contract with UPHP and coordinates the contracting process and ensures all steps of the process are completed timely. 3. Provides general support to providers seeking assistance through phone, email, mail, fax, etc. 4. Acts as liaison for provider offices and commercial companies utilizing the UPMC network. This includes handling identified system claims issues, reimbursement issues, and provider file maintenance; answers inquiries from providers about commercial companies; and investigates and resolves discrepancies associated with provider file information with the commercial companies. 5. Assists commercial companies under network access agreements and new companies inquiring about network access and contracting agreements; responsible for facilitating provider information updates to commercial companies. 6. Responsible for the execution, reporting, and file maintenance of site visit surveys. 7. Supports processes to ensure network provider data is accurate and inputs provider and group contract information into the CACTUS credentialing system; works with configuration staff to ensure accurate provider data is loaded into the Claims Processing System. 8. Provides support to other departments through verification of provider data, problem solving with provider offices, assisting and finalizing provider communication documents, and responding to access and availability provider related concerns and potential leads. 9. Assists in the planning and implementation of provider events, including, but not limited to provider in-service and educational webinars. 10. Assists in compliance reporting to Michigan Department of Health and Human Services (MDHHS) related to contracting, network adequacy and access, provider directory data, and provider network related policies. 11. Assists in ensuring compliance with State, Federal, and accrediting agencies’ network adequacy standards. Augments and modifies the provider network as needed in order to comply with applicable network adequacy standards, including those standards set forth by the Centers for Medicare and Medicaid Services (CMS). 12. Orients new and existing providers to the health plan; sends copies of provider material (i.e., provider newsletters, formulary) to providers. 13. Demonstrates knowledge of National Committee for Quality Assurance (NCQA) standards for contracting, site visits, access and availability and supports NCQA submissions. 14. Maintains confidentiality of client data. 15. Performs other related duties as assigned or requested. POSITION QUALIFICATIONS: Education: Minimum: Associate degree in business, office information services, health information processing, computer information systems, or related field Preferred: Bachelor’s degree in communications, public relations, business administration, or related field Experience: Minimum: One (1) to two (2) years of experience in health-care operations, provider relations, or customer service Preferred: Three (3) to four (4) years of customer relations experience in a health-care setting and/or a business background in health care; prior contracting experience Required Skills: Working knowledge of MS Office (Word, Excel, and PowerPoint) Excellent human relation and oral/written communication Excellent organizational and prioritization abilities with attention to detail The qualifications listed above are intended to represent the minimum skills and experience levels associated with performing the duties and responsibilities contained in this job description. The qualifications should not be viewed as expressing absolute employment or promotional standards but as general guidelines that should be considered along with other job-related selection or promotional criteria. Physical Requirements [This job requires the ability to perform the essential functions contained in the description. These include, but are not limited to, the following requirements. Reasonable accommodations may be made for otherwise qualified applicants unable to fulfill one or more of these requirements]: Ability to access departmental files Ability to enter and access information from a computer Ability to access all areas of the UPHP offices Moderate physical effort (lift/carry up to 25 pounds) Occasionally lifts supplies/equipment Occasional reaching, stooping, bending, kneeling, crouching Prolonged periods of sitting Occasional prolonged standing Manual dexterity and mobility Working Conditions Works in office conditions, but occasional travel may be required Exposure to situations requiring exceptional interpersonal skills or periods of intense concentration Subject to many interruptions Occasionally subjected to irregular hours

Responsibilities

This role manages provider relations for the network by integrating activities across claims, customer service, credentialing, and clinical departments, while also serving as a liaison for provider offices and commercial companies. Key duties include coordinating the contracting process, resolving claims and reimbursement issues, maintaining provider data in systems like CACTUS, and assisting with compliance reporting and provider events.