JOB REQUIREMENTS/QUALIFICATIONS

• 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. 

• Strong facilitation, presentation and analytical skills. 

PREFERRED REQUIREMENTS/QUALIFICATIONS

• Direct experience in healthcare payer environments is strongly preferred, including a solid understanding of healthcare contract reimbursement methodologies, medical claims processing, and provider payment structures (e.g., fee schedules, DRG, etc.).
• Advanced level of Excel fluency (i.e. pivot tables, data validation, handling large data sets)
• Experience loading, maintaining, and managing provider demographic data within healthcare systems.
• CRM or provider management systems knowledge.

~ KEY FUNCTIONALITY ~

• 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 with possible topics to 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 and performs investigative research upon the request of providers regarding the intricate and detailed information for all lines of business. 
• Maintains a thorough level of knowledge regarding all Provider Relations systems (e.g.: GUI, PPW, Salesforce, etc.) 

• Assists in conducting internal and external seminars and presentations as needed for the improvement of HCSC / provider relationships. 

• Lead internal and external meetings to assure and enhance provider success (e.g.: PowerPoint decks, Excel, analytics, presentation skills). 

• 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 cross-department workflows and projects and ensure appropriate provider services, including working across departments to resolve issues.   

• Ensure assigned providers are informed when changes occur and respond to provider inquiries in an effective and timely manner and coordinate claims resolution to payment problems.   

• Communicate and interact effectively and professionally with co-workers, management, customers, etc. 

• Comply with HIPAA, Diversity Principles, Corporate Integrity, Compliance Program policies and other applicable corporate and departmental policies. 

• Maintain complete confidentiality of company business. 

• Ensure all expenditures comply with corporate and divisional expense guidelines. 

• Maintain communication with management regarding development within areas of assigned responsibilities and perform special projects as required or requested. 

• Maintain accurate and timely documentation within Salesforce, ensuring all provider interactions, outreach activities, issue resolution, and key relationship management details are consistently recorded and updated to support business operations, reporting, and performance tracking. 

• Provide project support as needed, including tracking milestones, managing timelines, coordinating cross-functional activities, and contributing to project documentation and status updates. 
• Responsible for maintaining an up-to-date tracker of provider concerns and pain points and participate in discussions around resolutions. 

• Other duties as assigned by leadership.