Job Description

Your Role

The Provider Relations team oversees provider relationships and serves as the primary liaison between Blue Shield of California (BSC) and our contracted provider network. Our role is to support providers through education, issue resolution, and operational guidance, enabling them to effectively navigate our processes and consistently deliver high-quality care to our members.

The Provider Relations Representative, Senior will report to the Sr. Manager, Provider Contracting. In this role, you will be responsible for building and maintaining effective provider relationships with IPA/medical groups, PPO physicians, and hospitals, for all lines of business. This role entails delivering established quantifiable goals and targets for the assigned network of providers. Including the servicing of the designated provider network in the operational and compliance aspects of provider contracts. Additionally, you will interface daily with providers and internal constituents to effectively resolve service issues in a timely manner.

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 college degree or equivalent experience
• Requires 5 years of prior relevant experience working in Provider Relations across multiple lines of business, including strong provider engagement and relationship management
• 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 Provider Networks in California
• 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.

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.