Provider Relations Representative Senior

Profile

Provider Relations Representative, Senior','210028V','At Blue Shield of California we are parents, leader, students, visionaries, heroes, and providers. Everyday we come together striving to fulfill our mission, to ensure all Californians have access to high-quality health care at a sustainably affordable price. For more than 80 years, Blue Shield of California has been dedicated to transforming health care by making it more accessible, cost-effective, and customer-centric. We are a not-for-profit, independent member of the Blue Cross Blue Shield Association with 6,800 employees, more than $20 billion in annual revenue and 4.3 million members. The company has contributed more than $500 million to Blue Shield of California Foundation since 2002 to have a positive impact on California communities. Blue Shield of California is headquartered in Oakland, California with 18 additional locations including Sacramento, Los Angeles, and San Diego. We’re excited to share Blue Shield of California has received awards and recognition for – LGBT diversity, quality improvement, most influential women in corporate America, Bay Area’s top companies in volunteering & giving, and one of the world’s most ethical companies. Here at Blue Shield of California, we’re striving to make a positive change across our industry and the communities we live in – Join us!','!*!Job Summary

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 on 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.

 

Responsibilities

Execute on 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.

 

 

','!*!Knowledge and Experience

A minimum of a Bachelor’s degree in Social Work, Health Administration or related fields from an accredited university.

Valid CA Driver’s License and proof of auto insurance coverage required.

Typically, requires advanced knowledge of job area typically obtained through advanced education combined with experience. May have practical knowledge of project management.

Typically, requires a college degree or equivalent experience and minimum 5 years of prior relevant experience.

','!*!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. ','!*!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. ','','Provider Services','United States of America-California-Rancho Cordova','','Health Solutions','Full-time','Aug 2, 2021','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.','Provider Relations Representative, Senior

Company info

Blue Shield of California
Website : https://www.blueshieldca.com