About the role
Your Role
The Provider Relations team serves as the primary liaison between Blue Shield of California and its provider network, supporting providers through education, guidance, and issue resolution.
The Senior Provider Relations Representative builds provider relationships, supports contract compliance, and partners with providers and internal teams to resolve operational issues and achieve network goals.
Our leadership model is about developing great leaders at all levels and creating opportunities for our people to grow – personally, professionally, and financially. We are looking for leaders that are energized by creative and critical thinking, building and sustaining high-performing teams, getting results the right way, and fostering continuous learning.
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 your manager
Coordinate data extracts and data analysis interpretation in preparation of reports aimed at determining the 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
Emphasize on improving member’s experience and perception in Getting Needed Care and Getting Care Quickly to help achieve Blue Shield of California’s (BSC’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 BSC'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 bachelor’s degree or High School/GED plus 4 years of relevant experience
Requires 5 years of prior relevant experience
Requires experience working at a health plan (managed care, government payer, or academic)
Requires experience working directly with provider networks of CA.
Strong organizational and time management skills
Ability to manage multiple initiatives
Ability to present in group settings
Ability to independently drive issues to resolution and multi-task
Knowledge of regulatory requirements is preferred
Knowledge of delegation and oversight
Hybrid
This role requires employees to be in-office based on our hybrid workplace model, balancing purposeful in-person collaboration with flexibility. For most teams, this means coming into the office two days each week.
Employees living more than 50 miles from an office location will work with their manager to determine in-office time based on business need.