REQUIRED JOB QUALIFICATIONS

• Bachelor’s Degreeandthree (3)years of work experience in managed care OR aminimum offive (5) yearswork experience in a managed care environment.

• Two (2) years of healthcare administration experience in clinical and financial settings, with direct provider communication experience.

• Effective interpersonal, analytical,presentationand communication skills.

• Knowledge of the healthcare industry, healthcare systems and payer/provider dynamics.

• Ability and willingness to travel within assigned areas for responsibility, including overnight stays.

• Strong comprehension of contracts, applications, and products.

• Understanding ofprovider reimbursement methodologies and claims.

• Working knowledge of claims processing systems.

• Effective organizational and planning skills with the ability to take initiative and work independently.

• Demonstrated ability to meet deadlines and work well under pressure.

• Clear and concise interpersonal,verbaland written communication skills.

• Collaborationskills resulting in business/process improvements/changes.

• PC proficiency and skillsto includeWord, Excel, PowerPoint, etc.

• Strong facilitation,presentationand analytical skills.

PREFERRED JOB QUALIFICATIONS

• Advanced level of Excel fluency (i.e. pivot tables, data validation, handling large data sets)
• Strong familiarity with claims, billing, and coding basics (CPT, ICD-10 helpful).
• CRM or provider management systems knowledge.

~ KEY FUNCTIONS ~

• Establishes andmaintainsrelationships between Blue Cross andcontractedproviders to promote and ensure that BCBS networks areperforming perthe contracted agreement(e.g.Compliance,PEAQ,etc.).

• Act aspointof escalation for providersregardingaspects of theirrelationship with HCSC.Possible topicsincludeoperations,claims,financial reimbursement, policies, procedures, and contractual issues.

• Maintains a thorough level of knowledge for all lines of businessto ensure provider contract compliance.

• Performs investigative research upon the request of providersregardingthe intricate and detailed information for all lines of business.

• Assistsin conductinginternal and externalseminars and presentationsas needed for the improvement of HCSC / provider relationship.

• Prepare for and lead internal and external meetings toassureand enhance provider success (e.g.: PowerPoint decks, Excel, analytics, presentation skills).

• Maintains a thorough level of knowledgeregardingallProviderRelationssystems(e.g.: GUI, PPW,Salesforce, etc.)

• Provides training and education to all Blue Cross contractedproviders including, but not limited to,hospitals, physicians, free-standing surgery centers, free standing substance abuse facilities, free standing psych facilities, VA hospitals, and all other allied professional providers.

• Represent Provider Relations in cross-department workflows and projects.

• Ensureappropriate providerservices including working across departments to resolve issues.

• Ensure assigned providers are informed when changes occur.

• Respond to provider inquiries in an effective andtimelymanner and coordinate claims resolution to payment problems.

• Establish andmaintainrelationships with assigned providers through personal visits,correspondenceand telephone calls.

• Communicate and interact effectively and professionally with co-workers, management, customers, etc.

• Comply withHIPAA, Diversity Principles, Corporate Integrity, Compliance Program policies and other applicable corporate and departmental policies.

• Maintain complete confidentiality ofcompanybusiness.

• Ensure all expenditurescomply withcorporate and divisional expense guidelines.

• Maintain communication with managementregardingdevelopment within areas of assigned responsibilities and perform special projects asrequiredor requested.

• Responsible formaintainingan up-to-date tracker of provider concerns and pain points.Participate in discussions around resolutions.

• Maintainaccurateandtimelydocumentation within Salesforce, ensuring all provider interactions, outreach activities, issue resolution, and key relationship management details are consistently recorded and updated to support business operations, reporting, and performance tracking.

• Provide project support as needed, including tracking milestones, managing timelines, coordinating cross-functional activities, and contributing to project documentation and status updates.

• Other duties as assigned by leadership