Provider Relations Representative, Senior

About the 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.

Responsibilities

• 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
• Cooked up claim disputes and all necessary research timely and effectively
• Coordinate 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

Qualifications

• A bachelor’s degree or High School/GED plus 4 years of relevant experience
• 5 years of prior relevant experience
• Experience working at a health plan (managed care, government payer, or academic)
• 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

Benefits

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.

Our Values

Honest. We hold ourselves to the highest ethical and integrity standards. We build trust by doing what we say we're going to do and by acknowledging and correcting where we fall short. Human. We strive to listen and communicate effectively, showing empathy by understanding others' perspectives. Courageous. We stand up for what we believe in and are committed to the hard work necessary to achieve our ambitious goals.

About Us

About Blue Shield of California As of January 2025, Blue Shield of California became a subsidiary of Ascendiun. Ascendiun is a nonprofit corporate entity that is the parent to a family of organizations including Blue Shield of California and its subsidiary, Blue Shield of California Promise Health Plan; Altais, a clinical services company; and Stellarus, a company designed to scale healthcare solutions. Together, these organizations are referred to as the Ascendiun Family of Companies. At Blue Shield of California, our mission is to create a healthcare system worthy of our family and friends and sustainably affordable. We are transforming health care in a way that genuinely serves our nonprofit mission by lowering costs, improving quality, and enhancing the member and physician experience. To achieve our mission, we foster an environment where all employees can thrive and contribute fully to address the needs of the various communities we serve. We are committed to creating and maintaining a supportive workplace that upholds our values and advances our goals. Blue Shield is a U.S. News Best Company to work for, a Deloitte U.S. Best Managed Company and a Top 100 Inspiring Workplace. We were recognized by Fair360 as a Top Regional Company, and one of the 50 most community-minded companies in the United States by Points of Light. Here at Blue Shield, we strive to make a positive change across our industry and communities – join us!

Equal Employment Opportunity

External hires must pass a background check/drug screen. Qualified applicants with arrest records and/or conviction records will be considered for employment in a manner consistent with Federal, State and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regards to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or disability status and any other classification protected by Federal, State and local laws.