Provider Relations Representative, Senior

Your Role

The Provider Relations team serves as the intermediary between Blue Shield of California and the IPA/medical groups, hospitals, and PPO physicians in which they are responsible for maintaining long-term relationships with. The Provider Relations Representative, Senior is responsible for building relationships with IPA/medical groups, PPO physicians, and hospitals for all lines of business. This role entails delivering established quantifiable goals and targets for an assigned provider network of providers, and services the designated provider network in operational and compliance aspects of provider contracts. Reporting to the Manager, Provider Services, this role will work with providers and internal constituents to resolve service issues promptly and effectively. The ability to present in group settings and independently drive issues to resolution as well as effective multi-tasking skills that are critical for success.

Your work: 

In this role, you will:

• Develop and maintain deep and long-lasting relationships with providers
• Coordinate escalated claim disputes and all necessary research in a timely and effective manner
• Implement or support at least three geo-regional strategies with minimal support and guidance from the manager
• Coordinate data extracts and data analysis interpretation in preparation of reports to determine the necessity of rate increases to retain key PPO providers, with minimal support and guidance from the manager
• Conduct data-driven operations meetings with an assigned provider network, including IPA/medical groups, PPO providers/provider groups, and hospitals. 
• Demonstrate the ability to drive critical discussions with an 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
• Drive focused strategic outreach with Providers to ensure compliance with Accessibility and Availability, and ensure that New Provider Orientation within state and federal regulations are met 
• Implement strategies with providers to improve provider performance. 
• Customize special education needs for providers and deliver strategic communications to assigned providers with minimal guidance
• Execute crucial provider performance metrics by demonstrating quantifiable improvements that contribute to Blue Shield of California’s critical strategic goals, including but not limited to reducing network utilization to decrease the overall cost of healthcare

Your Knowledge and Experience

• Requires a college degree or equivalent experience
• Requires 5 years of prior relevant experience
• Strong organizational and time management skills
• Ability to manage multiple initiatives
• Knowledge of Provider Networks in California
• Appropriate knowledge of delegation and oversight
• Knowledge of regulatory requirements is preferred