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Job Summary

BASIC FUNCTION

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 is a TELECOMMUTE role; relocation is not available, sponsorship will not be extended either now or in the future.

REQUIRED JOB 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 JOB QUALIFICATIONS

• 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.

~ KEY FUNCTIONS ~

• 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 cross-department workflows and projects.

• Ensure appropriate provider services including working across departments to resolve issues.

• Ensure assigned providers are informed when changes occur.

• Respond to provider inquiries in an effective and timely manner and coordinate claims resolution to payment problems.

• Establish and maintain relationships with assigned providers through personal visits, correspondence and telephone calls.

• 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.

• Responsible for maintaining an up-to-date tracker of provider concerns and pain points. Participate in discussions around resolutions.

• 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.

• Other duties as assigned by leadership

Are you being referred to one of our roles? If so, ask your connection at HCSC about our Employee Referral process!

Pay Transparency Statement:

At Health Care Service Corporation, you will be part of an organization committed to offering meaningful benefits to our employees to support their life outside of work. From health and wellness benefits, 401(k) savings plan, pension plan, paid time off, paid parental leave, disability insurance, supplemental life insurance, employee assistance program, paid holidays, tuition reimbursement, plus other incentives, we offer a robust total rewards package for employees. Learn more about our benefit offerings by visiting https://careers.hcsc.com/totalrewards .

The compensation offered will vary depending on your job-related skills, education, knowledge, and experience. This role aligns with an annual incentive bonus plan subject to the terms and the conditions of the plan.

HCSC Employment Statement:

We are an Equal Opportunity Employment employer dedicated to providing a welcoming environment where the unique differences of our employees are respected and valued. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, protected veteran status, or any other legally protected characteristics.

Base Pay Range

$55,900.00 - $123,500.00

Exact compensation may vary based on skills, experience, and location.

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For more than 80 years, HCSC has been dedicated to expanding access to high-quality, cost-effective health care and equipping our members with information and tools to make the best health care decisions for themselves and their families. As an industry leader, HCSC also has been helping to make the health care system work better for all Americans. To remain a leader, we offer compelling careers that encourage resourcefulness, strategic thought and empower you to make a difference in the lives of our members and their communities.

Today, with the industry at an important crossroad, HCSC is reimagining health care and looking for original thinkers who aren't afraid to make innovative contributions. We are an Equal Opportunity Employment employer dedicated to workforce diversity and a drug-free and smoke-free workplace. Learn more about HCSC, our commitment to our members and the opportunity you'll have to improve health care delivery in an open, collaborative environment.

HCSC is committed to diversity in the workplace and to providing equal opportunity to employees and applicants.

If you are an individual with a disability or a disabled veteran and need an accommodation or assistance in either using the Careers website or completing the application process, you can call us at 1-866-977-7378 to request reasonable accommodations.

Please note that only requests for accommodations in the application process will be returned. All applications, including resumes, must be submitted through HCSC's Career website on-line application process. If you have general questions regarding the status of an existing application, navigate to "candidate home" to view your job submissions.

Blue Cross and Blue Shield of Illinois, Blue Cross and Blue Shield of Montana, Blue Cross and Blue Shield of New Mexico, Blue Cross and Blue Shield of Oklahoma, and Blue Cross and Blue Shield of Texas,

Divisions of Health Care Service Corporation, a Mutual Legal Reserve Company, and Independent Licensee of the Blue Cross and Blue Shield Association

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