Blue Shield Of California
Provider Relations Representative, Experienced
Blue Shield Of California, Woodland Hills, California, us, 91371
Job Description
Your Role
The Provider Relations Representative, Experienced is responsible for building and maintaining effective provider relationships with IPA/medical groups, PPO physicians, and hospitals, for all lines of business. The job entails delivering established quantifiable goals and targets for their assigned network of providers. Servicing the designated provider network in the operational and compliance aspects of provider contracts. Daily interface with providers and internal constituents to effectively resolve service issues in a timely manner is a requirement of the job. Ability to present in group settings, independently drive issues to resolution and multi-tasking are required.
Your Work
In this role, you will:Execute key provider performance metrics by demonstrating quantifiable improvements that contribute to Company's critical few strategic goals; including but not limited to reducing Out of Network utilization to decrease the overall Cost of Healthcare.Conduct data driven operations meetings with assigned network of providers which includes IPA/medical groups, PPO providers/provider groups and Hospitals; Ability to 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.External facing position that develops and maintains 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; Emphasis on improving member's experience and perception in Getting Needed Care and Getting Care Quickly to help achieve Blue Shield'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.Coordinate escalated claim disputes and all necessary research timely and effectively which may require some reliance on their manager and senior level peers in setting action plans to analyze and resolve root cause issues.Complete Transition and Disengagement Reports required by the Department of Manage Health care when IPAs/Medical Groups or Hospitals submit termination notices.Ability to lead ad-hoc projects/assignments and actively drive discussions in all internal and external meetings.The job requires high level of autonomy in decision making since PRC's main customers (providers) need to rely on the PRC's for answers to issues that need immediate resolutionAbility to work independently under limited supervision.Qualifications
Your Knowledge and Experience
Requires a bachelor's degree or equivalent experienceRequires at least 3 years of prior relevant experienceStrong analytical and problem-solving skillsProficiency in Microsoft office suite (Excel, Outlook, Access, and Word)General understanding of medical terminologyPrevious experience with Medi-Cal or MedicaidMust be able to work independentlyYour Pay
The pay range for this role is: $ 66770.00 to $ 93390.00 for California.
Note
Please note that this range represents the pay range for this and many other positions at Blue Shield that fall into this pay grade. Blue Shield salaries are based on a variety of factors, including the candidate's experience, location (California, Bay area, or outside California), and current employee salaries for similar roles.
#LI-AG3
About the Team
Blue Shield of California's mission is to ensure all Californians have access to high-quality health care at a sustainably affordable price. We are transforming health care in a way that genuinely serves our nonprofit mission by lowering costs, improving quality, and enhancing the member and physician experience.
To fulfill our mission, we must ensure a diverse, equitable, and inclusive environment where all employees can be their authentic selves and fully contribute to meet the needs of the multifaceted communities we serve. Our continued commitment to diversity, equity, and inclusion upholds our values and advances our goal of creating a healthcare system that is worthy of our family and friends while addressing health disparities, promoting social justice, and integrating health equity through our products, business practices, and presence as a corporate citizen.
Blue Shield has received awards and recognition for being a certified Fortune 100 Best Companies to Work, Military Friendly Employer, People Companies that Care, a Leading Disability Employer, and one of California's top companies in volunteering and giving. Here at Blue Shield, we strive to make a positive change across our industry and communities - join us!
Our Values:
Honest . We hold ourselves to the highest ethical and integrity standards. We build trust by doing what we say we're going to do and by acknowledging and correcting where we fall short.Human . We strive to be our authentic selves, listening and communicating effectively, and showing empathy towards others by walking in their shoes.Courageous . We stand up for what we believe in and are committed to the hard work necessary to achieve our ambitious goals.Our Workplace Model:
Blue Shield of California is dedicated to making work-life balance a reality. Whether you prefer to work in an office or from home, we understand flexibility is more important than ever. That's why Blue Shield is a hybrid company, offering you the opportunity to decide where you can do your best and most meaningful work.
Two ways of working: Hybrid (our default) and office
Hybrid - In a business unit approved office a few times per year to 3 days per week, on averageOffice - In a business unit approved office 4+ days a week, on average. If the role you're applying for is deemed an "Essential Role," the company has determined that the role can only be performed in a Blue Shield office or in the field and would require your to meet the office worker classification.
Physical Requirements:
Office Environment - roles involving part to full time schedule in Office Environment. Due to the current public health emergency in California, Blue Shield employees are almost all working remotely. 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.
Equal Employment Opportunity:
External hires must pass a background check/drug screen. Qualified applicants with arrest records and/or conviction records will be considered for employment in a manner consistent with Federal, State and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regards to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or disability status and any other classification protected by Federal, State and local laws.
Your Role
The Provider Relations Representative, Experienced is responsible for building and maintaining effective provider relationships with IPA/medical groups, PPO physicians, and hospitals, for all lines of business. The job entails delivering established quantifiable goals and targets for their assigned network of providers. Servicing the designated provider network in the operational and compliance aspects of provider contracts. Daily interface with providers and internal constituents to effectively resolve service issues in a timely manner is a requirement of the job. Ability to present in group settings, independently drive issues to resolution and multi-tasking are required.
Your Work
In this role, you will:Execute key provider performance metrics by demonstrating quantifiable improvements that contribute to Company's critical few strategic goals; including but not limited to reducing Out of Network utilization to decrease the overall Cost of Healthcare.Conduct data driven operations meetings with assigned network of providers which includes IPA/medical groups, PPO providers/provider groups and Hospitals; Ability to 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.External facing position that develops and maintains 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; Emphasis on improving member's experience and perception in Getting Needed Care and Getting Care Quickly to help achieve Blue Shield'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.Coordinate escalated claim disputes and all necessary research timely and effectively which may require some reliance on their manager and senior level peers in setting action plans to analyze and resolve root cause issues.Complete Transition and Disengagement Reports required by the Department of Manage Health care when IPAs/Medical Groups or Hospitals submit termination notices.Ability to lead ad-hoc projects/assignments and actively drive discussions in all internal and external meetings.The job requires high level of autonomy in decision making since PRC's main customers (providers) need to rely on the PRC's for answers to issues that need immediate resolutionAbility to work independently under limited supervision.Qualifications
Your Knowledge and Experience
Requires a bachelor's degree or equivalent experienceRequires at least 3 years of prior relevant experienceStrong analytical and problem-solving skillsProficiency in Microsoft office suite (Excel, Outlook, Access, and Word)General understanding of medical terminologyPrevious experience with Medi-Cal or MedicaidMust be able to work independentlyYour Pay
The pay range for this role is: $ 66770.00 to $ 93390.00 for California.
Note
Please note that this range represents the pay range for this and many other positions at Blue Shield that fall into this pay grade. Blue Shield salaries are based on a variety of factors, including the candidate's experience, location (California, Bay area, or outside California), and current employee salaries for similar roles.
#LI-AG3
About the Team
Blue Shield of California's mission is to ensure all Californians have access to high-quality health care at a sustainably affordable price. We are transforming health care in a way that genuinely serves our nonprofit mission by lowering costs, improving quality, and enhancing the member and physician experience.
To fulfill our mission, we must ensure a diverse, equitable, and inclusive environment where all employees can be their authentic selves and fully contribute to meet the needs of the multifaceted communities we serve. Our continued commitment to diversity, equity, and inclusion upholds our values and advances our goal of creating a healthcare system that is worthy of our family and friends while addressing health disparities, promoting social justice, and integrating health equity through our products, business practices, and presence as a corporate citizen.
Blue Shield has received awards and recognition for being a certified Fortune 100 Best Companies to Work, Military Friendly Employer, People Companies that Care, a Leading Disability Employer, and one of California's top companies in volunteering and giving. Here at Blue Shield, we strive to make a positive change across our industry and communities - join us!
Our Values:
Honest . We hold ourselves to the highest ethical and integrity standards. We build trust by doing what we say we're going to do and by acknowledging and correcting where we fall short.Human . We strive to be our authentic selves, listening and communicating effectively, and showing empathy towards others by walking in their shoes.Courageous . We stand up for what we believe in and are committed to the hard work necessary to achieve our ambitious goals.Our Workplace Model:
Blue Shield of California is dedicated to making work-life balance a reality. Whether you prefer to work in an office or from home, we understand flexibility is more important than ever. That's why Blue Shield is a hybrid company, offering you the opportunity to decide where you can do your best and most meaningful work.
Two ways of working: Hybrid (our default) and office
Hybrid - In a business unit approved office a few times per year to 3 days per week, on averageOffice - In a business unit approved office 4+ days a week, on average. If the role you're applying for is deemed an "Essential Role," the company has determined that the role can only be performed in a Blue Shield office or in the field and would require your to meet the office worker classification.
Physical Requirements:
Office Environment - roles involving part to full time schedule in Office Environment. Due to the current public health emergency in California, Blue Shield employees are almost all working remotely. 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.
Equal Employment Opportunity:
External hires must pass a background check/drug screen. Qualified applicants with arrest records and/or conviction records will be considered for employment in a manner consistent with Federal, State and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regards to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or disability status and any other classification protected by Federal, State and local laws.