Your Role

The Provider Support team for Claims and Payment Models is a specialized unit within the Network Management and Provider Partnerships organization that is accountable for improving the provider experience and streamlining operations. The Provider Relations Representative, Consultant will report to the Senior Manager. In this role you will be responsible for assisting providers including Facilities, Large Systems, and Physicians contracted for value-based payment models with escalated claims and payment issues. Internally, you will be responsible for partnering with cross functional teams including Provider Relations, Contracting, Claims, Clinical, Legal & Compliance, Data Analytics, Information Technology, and Innovation to facilitate issue resolution, identify root causes, and deliver operational improvements.

Your Work

In this role, you will:

• Implement strategies with providers to improve provider performance. Develop and maintain good working relationships with the provider community
• Serve as liaison between the company and the provider community to resolve questions or problems such as contract interpretation, product/program implementation and claims administration
• Ensure provider compliance with company policies and contractual agreement
• Be responsible for having proactive data driven discussions to improve provider performance
• Coordinate escalated claim disputes and all necessary research timely and effectively with minimal guidance from manager in setting action plans to analyze and resolve root cause
• Work to achieve operational targets with significant impact on the departmental results
• Contribute to the development of goals for the department and planning efforts (budgets, operational plans, etc.)
• Influence the performance of the business unit or related functional areas in achieving Blue Shield of California’s objectives 
• Manage large projects or processes that span outside of immediate job area
• Be responsible for making moderate to significant improvements of processes, systems or products to enhance performance of the job area 
• Develop new perspectives and innovative approaches on existing problems. Issues faced are numerous and undefined, and require detailed information gathering, analysis and investigation to understand the problem. Problems are difficult and moderately complex, typically impact multiple departments or specialties, and are usually solved through drawing from prior experience and analysis of issues
• Communicate and work to influence parties within and outside the job function at an operational level regarding policies, procedures and practices
• Be responsible for providing guidance, coaching and training to other employees within job area
• Be responsible for managing major/complex projects involving delegation of work and review of work products