Provider Relations Representative, Experienced

Your Role

The Provider Relations Representative, Experienced is responsible for building and maintaining effective provider relationships with IPA/medical groups, PPO physicians, and hospitals, for all lines of business. The job entails delivering established quantifiable goals and targets for their assigned network of providers. Servicing the designated provider network in the operational and compliance aspects of provider contracts. Daily interface with providers and internal constituents to effectively resolve service issues in a timely manner is a requirement of the job. Ability to present in group settings, independently drive issues to resolution and multi-tasking are required.

Your Work

In this role, you will:

• Execute key provider performance metrics by demonstrating quantifiable improvements that contribute to Company's critical few strategic goals; including but not limited to reducing Out of Network utilization to decrease the overall Cost of Healthcare.
• Conduct data driven operations meetings with assigned network of providers which includes IPA/medical groups, PPO providers/provider groups and Hospitals; Ability to drive critical discussions with assigned network of providers to deliver established quantifiable goals and targets.
• Support assigned provider book of business in a customer-focused, effective and efficient manner.
• External facing position that develops and maintains deep and long-lasting relationships with providers.
• Drive focused strategic outreach with Providers to ensure compliance with Accessibility and Availability within state and federal regulations are met; Emphasis on improving member's experience and perception in Getting Needed Care and Getting Care Quickly to help achieve Blue Shield's mission to meet a Medicare STAR 4 (or better) rating.
• Implement strategies with providers to improve provider performance. Customize special education needs for providers as well as delivering strategic communications to assigned providers with good level of self-reliance.
• Coordinate escalated claim disputes and all necessary research timely and effectively which may require some reliance on their manager and senior level peers in setting action plans to analyze and resolve root cause issues.
• Complete Transition and Disengagement Reports required by the Department of Manage Health care when IPAs/Medical Groups or Hospitals submit termination notices.
• Ability to lead ad-hoc projects/assignments and actively drive discussions in all internal and external meetings.
• The job requires high level of autonomy in decision making since PRC's main customers (providers) need to rely on the PRC's for answers to issues that need immediate resolution
• Ability to work independently under limited supervision.

Your Knowledge and Experience

• Requires a bachelor's degree or equivalent experience
• Requires at least 3 years of prior relevant experience
• Strong analytical and problem-solving skills
• Proficiency in Microsoft office suite (Excel, Outlook, Access, and Word)
• General understanding of medical terminology
• Previous experience with Medi-Cal or Medicaid
• Must be able to work independently

Your Pay

The pay range for this role is: $ 66770.00 to $ 93390.00 for California.

Note

Please note that this range represents the pay range for this and many other positions at Blue Shield that fall into this pay grade. Blue Shield salaries are based on a variety of factors, including the candidate's experience, location (California, Bay area, or outside California), and current employee salaries for similar roles.

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