Job Description

Your Role

The Provider Relations team serves as the primary liaison between Blue Shield of California and its provider network, supporting providers through education, guidance, and issue resolution.

The Senior Provider Relations Representative builds provider relationships, supports contract compliance, and partners with providers and internal teams to resolve operational issues and achieve network goals.

Responsibilities

Your Work

In this role, you will:

• Implement strategies with providers to improve provider performance
• Customize special education needs for providers as well as delivering strategic communications to assigned providers with minimal guidance
• Coordinate escalated claim disputes and all necessary research timely and effectively
• Implement or support at least three geo-regional strategies with minimal support and guidance from your manager
• Coordinate data extracts and data analysis interpretation in preparation of reports aimed at determining the necessity of rate increases to retain key PPO providers, with minimal support and guidance from manager
• Conduct data driven operations meetings with assigned network of providers which includes IPA/medical groups, PPO providers/provider groups and Hospitals
• 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
• Develop and maintain 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
• Emphasize on improving member's experience and perception in Getting Needed Care and Getting Care Quickly to help achieve Blue Shield of California's (BSC'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
• Execute on key provider performance metrics by demonstrating quantifiable improvements that contribute to BSC's critical few strategic goals, including but not limited to reducing Out of Network utilization to decrease the overall Cost of Healthcare

Qualifications

Your Knowledge and Experience

• Requires a bachelor's degree or High School/GED plus 4 years of relevant experience
• Requires 5 years of prior relevant experience
• Requires experience working at a health plan (managed care, government payer, or academic)
• Requires experience working directly with provider networks of CA.
• Strong organizational and time management skills
• Ability to manage multiple initiatives
• Ability to present in group settings
• Ability to independently drive issues to resolution and multi-task
• Knowledge of regulatory requirements is preferred
• Knowledge of delegation and oversight

Hybrid

This role requires employees to be in-office based on our hybrid workplace model, balancing purposeful in-person collaboration with flexibility. For most teams, this means coming into the office two days each week.

Employees living more than 50 miles from an office location will work with their manager to determine in-office time based on business need.

Our Workplace Model

We believe in fostering a workplace environment that balances purposeful in-person collaboration with flexibility - providing clear expectations while respecting the diverse needs of our workforce. Our workplace model is designed around intentional in-person interaction, collaboration, connection, creativity and flexibility:

• For most teams, this means coming into the office two days per week.
• Employees living more than 50 miles from an office location, out of state employees, and employees in certain member-facing roles should work with their manager to determine in-office time based on business need.
• For employees with medical conditions that may impact their ability to work in-office, we are committed to engaging in an interactive process and providing reasonable accommodations to ensure their work environment is conducive to their success and well-being.

The Company reserves the right to require more presence in the office based on business needs, and requirements are subject to change with periodic reviews.

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.