Provider Relations Representative HYBRID

Job Title

This position is responsible for the contracting, credentialing, and maintenance of professional provider data to support marketing, membership and network contracting across all lines of business; building relations with the provider community is an important part of this role.

Responsibilities include promoting high quality initiatives to support data integrity; accepting ownership and leading highly specialized operational and customer support duties that require independent initiative. This role includes participating in internal provider meetings and work groups, researching problems related to provider credentialing, data and network participation. Incumbent also provides training and education to all Blue Cross contracted providers including, but not limited to: hospitals, physicians, free-standing surgery centers, free standing substance abuse facilities, free standing psych facilities, VA hospitals, and all other allied professional providers.

Note:

This role is HYBRID/FLEX and requires in-office visibility three days per week, working from home the other two days. Relocation is not available, sponsorship will not be extended either now or in the future.

• Bachelor's degree and three (3) years of work experience in managed care OR a minimum of five (5) years work experience in a managed care environment.
• Two (2) years of healthcare administration experience in clinical and financial settings, with direct provider communication experience.
• Effective interpersonal, analytical, presentation and communication skills.
• Knowledge of the healthcare industry, healthcare systems and payer/provider dynamics.
• Ability and willingness to travel within assigned areas for responsibility, including overnight stays.
• Strong comprehension of contracts, applications, and products.
• Understanding of provider reimbursement methodologies and claims.
• Working knowledge of claims processing systems.
• Effective organizational and planning skills with the ability to take initiative and work independently.
• Demonstrated ability to meet deadlines and work well under pressure.
• Clear and concise interpersonal, verbal and written communication skills.
• Collaboration skills resulting in business/process improvements/changes.
• PC proficiency and skills to include Word, Excel, PowerPoint, etc.
• Excellent facilitation, presentation and research skills.

• Advanced level of Excel fluency (i.e. pivot tables, data validation, handling large data sets)
• Strong familiarity with claims, billing, and coding basics (CPT, ICD-10 helpful)
• CRM or provider management systems knowledge
• Affiliation with IAMHP (Illinois Association of Medicaid Health Plans)
• Experience working with government agencies, legislative and advocacy groups

• Establishes and maintains relationships between Blue Cross and contracted providers to promote and ensure that BCBS networks are performing per the contracted agreement (e.g. Compliance, PEAQ, etc.).
• Act as point of escalation for providers regarding aspects of their relationship with HCSC. Possible topics include operations, claims, financial reimbursement, policies, procedures, and contractual issues.
• Maintains a thorough level of knowledge for all lines of business to ensure provider contract compliance.
• Performs investigative research upon the request of providers regarding the intricate and detailed information for all lines of business.
• Assists in conducting internal and external seminars and presentations as needed for the improvement of HCSC / provider relationship.
• Prepare for and lead internal and external meetings to assure and enhance provider success (e.g.: PowerPoint decks, Excel, analytics, presentation skills).
• Maintains a thorough level of knowledge regarding all Provider Relations systems (e.g.: GUI, PPW, Salesforce, etc.)
• Provides training and education to all Blue Cross contracted providers including, but not limited to, hospitals, physicians, free-standing surgery centers, free standing substance abuse facilities, free standing psych facilities, VA hospitals, and all other allied professional providers.
• Represent Provider Relations in…