Provider Relations Representative HYBRID

About the role

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 relationships with the provider community is a key aspect of this role. The position promotes high-quality initiatives to support data integrity, leads specialized operational and customer support duties, and participates in internal provider meetings and work groups.

Responsibilities

• Establish and maintain relationships between Blue Cross and contracted providers to ensure network performance aligns with contracted agreements (e.g., Compliance, PEAQ).
• Act as a point of escalation for providers regarding operations, claims, financial reimbursement, policies, procedures, and contractual issues.
• Maintain thorough knowledge of all lines of business to ensure provider contract compliance.
• Perform investigative research for providers regarding intricate and detailed information across all lines of business.
• Assist in conducting internal and external seminars and presentations to improve HCSC/provider relationships.
• Prepare and lead internal and external meetings to enhance provider success (e.g., PowerPoint decks, Excel analytics, presentation skills).
• Maintain knowledge of Provider Relations systems (e.g., GUI, PPW, Salesforce).
• Provide training and education to all Blue Cross contracted providers, including hospitals, physicians, surgery centers, substance abuse facilities, psych facilities, VA hospitals, and allied professional providers.
• Represent Provider Relations in cross-department workflows and projects to resolve issues and ensure provider services.
• Keep assigned providers informed of changes and respond to inquiries effectively and timely, coordinating claims resolution and payment problems.
• Establish and maintain provider relationships through visits, correspondence, and telephone calls.
• Comply with HIPAA, Diversity Principles, Corporate Integrity, and Compliance Program policies.
• Maintain confidentiality of company business and ensure expenditures comply with corporate guidelines.
• Maintain an up-to-date tracker of provider concerns and pain points, participating in resolution discussions.
• Document provider interactions, outreach activities, issue resolution, and relationship management details in Salesforce.
• Provide project support, including tracking milestones, managing timelines, and coordinating cross-functional activities.
• Perform other duties as assigned by leadership.

Requirements

• Bachelor’s Degree and three (3) years of work experience in managed care OR a minimum of five (5) years of 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, 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 to drive business/process improvements.
• PC proficiency, including Word, Excel, PowerPoint, etc.
• Excellent facilitation, presentation, and research skills.

Preferred Qualifications

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

Schedule

This role is hybrid/flex, requiring in-office visibility three days per week and remote work the other two days.

Pay

Compensation range: $55,900.00 - $123,500.00. Exact compensation may vary based on skills, experience, and location.