Provider Network Advocate

Job Description

Job Description

Provider Network Advocate

This role serves as the vital bridge between a health insurance company (payor) and the hospitals, doctors, and clinics (healthcare providers) that deliver care to members.

Role Type: Full-Time, Regular Employee of the Company (Not a temp or contract assignment)

Shift: Day Job (Standard business hours; occasionally requires extended hours beyond a 40-hour workweek based on project demands)

Work Arrangement: Hybrid (Minimum of 3 days per week on-site in Downtown Pittsburgh with occasional local travel for provider site visits)

Location: Pittsburgh, PA 15219

New Hire Starting Salary Range: $27.89 – $32.97 per hour (After hire, pay increases can be earned, see below).

About the Opportunity

This role is a permanent, full-time career opportunity within a premier national health plan network management division. If selected, you will be hired directly as a regular employee of the organization we represent. You will be on their payroll and eligible for their full suite of benefits from your start date. This is not a temporary, contract, or "temp-to-hire" role. This position features a collaborative hybrid layout, blending central corporate headquarters operations with localized community provider engagement.

Purpose

The Provider Network Advocate (PNA) specializes in investigating complex medical claims, supporting network providers, and cultivating strong strategic partnerships. Working in tandem with the Provider Network Liaison (PNL) team, this professional investigates systemic issues across internal departments, performs root-cause analysis, and deploys targeted outreach to resolve complex payment and configuration issues. This role is essential for driving provider operational satisfaction while championing key healthcare quality and compliance initiatives (including HEDIS, HCC, CDPS, and CMS Stars improvements).

Responsibilities

• Issue Investigation & Resolution: Coordinate multi-departmental problem resolution for provider issues identified through internal data reports or leadership escalations. Conduct deep-dive claims investigations to uncover root causes and ensure a closed feedback loop with the provider.
• Provider Outreach & Engagement: Conduct strategic outreach via telephone, email, and in-person site visits to educate network providers and their administrative office staff on health plan programs, electronic tools, and dynamic operational initiatives.
• Quality Initiative Support: Partner with providers on clinical documentation and performance improvement metrics tied directly to HEDIS, HCC, CDPS, Medical Advantage Pay-for-Performance (MA P4P), and CMS Stars ratings.
• CRM Database Management: Document all provider touchpoints, outreach metrics, and ongoing initiative milestones inside the internal customer relationship management database in a highly detailed, time-sensitive manner.
• Process Improvement: Collaborate actively with internal Network Leaders and cross-functional teams to identify administrative bottlenecks and enact continuous process improvements across the department.
• Special Project Management: Lead and execute special operational projects as assigned by leadership, representing the department at internal stakeholder assemblies and external provider meetings.

Minimum Essential Requirements

• Education Pathways: Bachelor’s Degree in Business, Healthcare Administration, Marketing, or a closely related field OR equivalent professional experience.
• Core Experience: Minimum of three (3) years of progressive experience in business, sales, or a healthcare-related corporate environment.
• Direct professional experience within Provider Services, Medical Claims processing, or Member Services—specifically utilizing claims investigation or root-cause problem analysis frameworks
• Technical Compliance: Exceptional organizational, analytical, and problem-solving skills. Proven ability to document complex workflows and communicate technical information clearly to executive leadership and external clinical partners.
• Mobility: Ability to travel occasionally throughout the regional area to conduct face-to-face provider site visits and accompany directors to external meetings.

Performance-Based Earning Potential

This role offers a structured path for financial advancement. Through consistent high performance, leadership development, and continuous learning over time, employees have the opportunity to earn up to $48.21 per hour .

Premier Benefits

• Exceptional Retirement Package: Retirement plans with employer matching. Combined, the organization contributes up to 8% of your eligible pay toward your future.
• World-Class Healthcare: Access preventive care and specialty services through an exclusive provider network.
• Generous Paid Time Off: Enjoy up to 5.5 weeks of PTO per year, plus 7 paid holidays, with unique options to buy or sell PTO days to fit your lifestyle.
• Tuition Assistance: Benefit from up to $6,000 per academic year in tuition reimbursement, plus exclusive tuition discounts at over 30 partner colleges and universities.