Provider Relations Representative, Experienced

Job Description

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.

Qualifications

Your Knowledge and Experience

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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About the Team

Blue Shield of California's mission is to ensure all Californians have access to high-quality health care at a sustainably affordable price. We are transforming health care in a way that genuinely serves our nonprofit mission by lowering costs, improving quality, and enhancing the member and physician experience.

To fulfill our mission, we must ensure a diverse, equitable, and inclusive environment where all employees can be their authentic selves and fully contribute to meet the needs of the multifaceted communities we serve. Our continued commitment to diversity, equity, and inclusion upholds our values and advances our goal of creating a healthcare system that is worthy of our family and friends while addressing health disparities, promoting social justice, and integrating health equity through our products, business practices, and presence as a corporate citizen.

Blue Shield has received awards and recognition for being a certified Fortune 100 Best Companies to Work, Military Friendly Employer, People Companies that Care, a Leading Disability Employer, and one of California's top companies in volunteering and giving. Here at Blue Shield, we strive to make a positive change across our industry and communities - join us!

Our Values :

Our Workplace Model :

At Blue Shield of California, we believe in fostering a workplace environment that balances purposeful in-person collaboration with flexibility. As we continue to evolve our workplace model, our focus remains on creating spaces where our people can connect with purpose - whether working in the office or through a hybrid approach - by providing clear expectations while respecting the diverse needs of our workforce.

Two Ways of Working :

Member-facing and approved out-of-state roles remain remote.

Physical Requirements :

Office Environment - roles involving part to full time schedule in Office Environment. Based in our physical offices and work from home office / deskwork - Activity level : Sedentary, frequency most of work day.

Please click here for further physical requirement detail.

Equal Employment Opportunity :

External hires must pass a background check / drug screen. Qualified applicants with arrest records and / or conviction records will be considered for employment in a manner consistent with Federal, State and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regards to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or disability status and any other classification protected by Federal, State and local laws.

Salary : $66,770 - $93,390