Provider Solutions Consultant
Job Description
The Provider Payment Solutions Consultant (PSC) works in partnership with Provider Payment Solutions team and Blue KC Account Executives and Account Managers across all lines of business to evaluate and monitor Blue KC’s provider service performance; recommends action plans to resolve provider service issues.
High Level of Critical Thinking
Proactively defines overall direction, roadmap and improvement actions for Provider Solutions functions that are core to the BlueKC business
Create and Utilize Tools
Utilizes tools to proactively evaluate performance so that actions can be recommended and taken to directly impact the results in a timely manner.
Accountable for Key Provider Relationships
Accountable for key Provider Relationships especially as it relates to claims not paying correctly
Identify, Triage, and Prioritize Issues
Identifies, triages, and prioritizes issues with input from cross-functional partners.
Drive Solutions
Drives solutions of production and payment issues based on an in-depth understanding of systems and system functionality.
Conduct Research and Analysis
Regularly conducts research and analysis of provider service issues based on performance reports and service data sets; assesses issues to determine root causes and issue impact areas and makes process improvement recommendations.
Manage Action Plans
Manages action plans to resolve service issues which could lead to new or updates to corporate and departmental policies, procedures, and workflows.
Communicate Effectively
Communicates effectively with team members and team leadership
Participate in Provider Service Management Team
Participates as needed in Provider Service Management Team (cross-functional team designed to discuss, prioritize and resolve provider service issues).
Coordinate and Facilitate Efforts
Collaborates with small teams within and across departments.
Develop Relationships
Manages collaborative provider relationships by leading meetings with providers to resolve complex issues and review of claim action logs.
Track and Analyze Metrics
Tracks, analyzes and communicates key metrics related to specific issues/projects.
Lead Discussions on Complex Issues
Independently provides analysis and leads discussion specific to the interaction of clinical reimbursement and benefit strategies for complex, cross-functional provider payment issues.
Minimum Qualifications
- Bachelor’s degree in Clinical Sciences or Business Administration or any combination of education and experience providing the types and level of knowledge, skills and ability required by the job.
- 5 – 7 years of professional experience working with operational and/or analytic processes, preferably within the healthcare industry or managed care payor
- Strong understanding of Blue KC core systems (including but not limited to Facets, ClaimsXten, NetworX)
- Strong understanding of claims, reimbursement, and benefit structures
- Strong professional communicator in both oral and written forms
- Demonstrated organizational, planning, and administrative skills
- Ability to work under pressure with limited resources, competing priorities and specific project timelines
- Self-starter; ability to work with minimal direction
Preferred Qualifications
- 7 years of professional experience working with operational and/or analytic processes, preferably within the healthcare industry or managed care payor
- Extensive understanding of Blue KC Claims, Reimbursement and Benefit Structures