Blue Cross and Blue Shield of Kansas City

Provider Solutions Consultant

Blue Cross and Blue Shield of Kansas City • $75K — $95K *
US-AnywhereRemote in Missouri, US
Healthcare
5 - 7 years of experience
Today
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Job Overview by Ladders

Qualifications

  • Bachelor's degree in Clinical Sciences or Business Administration or equivalent experience.
  • 5-7 years in operational/analytic processes, ideally in healthcare or managed care.
  • Strong understanding of Blue KC core systems such as Facets and ClaimsXten.
  • Proficient in claims, reimbursement, and benefit structures.
  • Exceptional oral and written communication skills.
  • Skilled in Microsoft Office Suite including Word, Excel, Access, and PowerPoint.
  • Strong organizational, planning, and administrative abilities.

Responsibilities

  • Evaluate and monitor provider service performance to recommend improvement actions.
  • Create tools to assess performance and drive timely interventions.
  • Manage key provider relationships related to claims discrepancies.
  • Identify and prioritize issues with input from cross-functional teams.
  • Conduct research and analysis to determine root causes of service issues.
  • Develop and oversee action plans to enhance policies and workflows.
  • Facilitate collaboration across departments to resolve provider issues.

Benefits

  • Opportunity to work collaboratively with cross-functional teams.
  • Engagement in strategic discussions impacting provider payments.
  • Development of relationships with providers for enhanced service delivery.
  • Participation in monthly performance tracking and scorecard creation.
  • Flexible work environment with a focus on proactive problem-solving.
Full Job Description
Job Description Summary:
The Provider Payment Solutions Consultant (PSC) works in partnership with Provider Payment Solutions team and Blue KC Account Executives and Account Managers across all lines of business to evaluate and monitor Blue KC's provider service performance; recommends action plans to resolve provider service issues.

Job Description
  • High level of Critical Thinking, ability to Think Outside of the Box to drive Resolution
  • Proactively defines overall direction, roadmap and improvement actions for Provider Solutions functions that are core to the BlueKC business
  • Create and utilize tools to proactively evaluate performance so that actions can be recommended and taken to directly impact the results in a timely manner.
  • Accountable for key Provider Relationships especially as it relates to claims not paying correctly
  • Identify, triage, and prioritize issues with input from cross-functional partners.
  • Drives solutions of production and payment issues based on an in-depth understanding of systems and system functionality. Regularly conduct research and analysis of provider service issues based on performance reports and service data sets; Assess issues to determine root causes and issue impact areas and make process improvement recommendations.
  • Manage action plans to resolve service issues which could lead to new or updates to corporate and departmental policies, procedures, and workflows.
  • Communicates effectively with team members and team leadership
  • Participate as needed in Provider Service Management Team (cross-functional team designed to discuss, prioritize and resolve provider service issues).
  • Coordinate and facilitate small team efforts within and across departments.
  • Develop proactive and positive working relationships with other departments within Blue KC to resolve provider issues.
  • Manage collaborative provider relationships by leading meetings with provider to resolve complex issues and review of claim action logs
  • Responsible for completing monthly provider service scorecards within timelines and performance of data integrity audits to ensure scorecard data is reasonable and accurate.
  • Tracks, analyzes and communicates key metrics related to specific issues/projects
  • Independently provides analysis and leads discussion specific to the interaction of clinical reimbursement and benefit strategies for complex, cross-functional provider payment issues.


Minimum Qualifications
  • Bachelor's degree in Clinical Sciences or Business Administration or any combination of education and experience providing the types and level of knowledge, skills and ability required by the job.
  • 5 - 7 years of professional experience working with operational and/or analytic processes, preferably within the healthcare industry or managed care payor
  • Strong understanding of Blue KC core systems (including but not limited to Facets, ClaimsXten, NetworX)
  • Strong understanding of claims, reimbursement, and benefit structures
  • Strong professional communicator in both oral and written forms
  • Strong knowledge and skills using Microsoft Word, Excel, Access, and PowerPoint, or similar PC-based software.
  • Demonstrated organizational, planning, and administrative skills.
  • Ability to work under pressure with limited resources, competing priorities and specific project timelines.
  • Self-starter; ability to work with minimal direction


Preferred Qualifications
  • 7 years of professional experience working with operational and/or analytic processes, preferably within the healthcare industry or managed care payor
  • Extensive understanding of Blue KC Claims, Reimbursement and Benefit Structures

About Blue Cross and Blue Shield of Kansas City

Blue Cross and Blue Shield of Kansas City is a not-for-profit health insurance provider that has been serving the Kansas City area for over 80 years. The company offers a variety of health insurance plans for individuals, families, and businesses, as well as Medicare Advantage plans and prescription drug coverage. Blue KC is committed to improving the health and wellness of its members and the community through various programs and initiatives.
Learn more about Blue Cross and Blue Shield of Kansas City
Size
3,000 employees
Industry
Healthcare
* Ladders Estimates

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