Your Role

The Provider Relations Representative, Senior is responsible for building and maintaining effective provider relationships with IPA/medical groups, PPO physicians, and hospitals, for all lines of business. Reporting to the Sr. Manager, Provider Contracting, this role entails delivering established quantifiable goals and targets for their assigned network of providers and servicing the designated provider network in the operational and compliance aspects of provider contracts. Additionally, this role involves daily interfacing with providers and internal constituents to effectively resolve service issues in a timely manner. The ability to present in group settings, independently drive issues to resolution and multi-tasking are critical.

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 manager
• Coordinate data extracts and data analysis interpretation in preparation of reports aimed to determine 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; 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
• Execute on key provider performance metrics by demonstrating quantifiable improvements that contribute to Blue Shield's critical few strategic goals; including but not limited to reducing Out of 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
• Knowledge of regulatory requirements is preferred
• Knowledge of Provider Networks in California is preferred
• Ability to manage multiple initiatives is preferred
• Strong organizational and time management skills is preferred
• Appropriate delegation and oversight

Pay Range:

The pay range for this role is: $77,990.00 to $116,930.00 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.

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