Director, Provider Services - Relations

Blue Shield of California•Long Beach, CA

About The Position

Your Role Reporting to the VP, Network Operations, the Director, Provider Services - Relations, Blue Shield of California and Promise Health Plan (BSCPHP), is responsible for creating and maintaining high integrity relationships with risk-baring medical providers, hospitals and health systems in their assigned region to enable BSCPHP to become the health plan of choice. The outcome of being the ideal partner for our providers will be to materially improve cost, quality, maintain compliance, service and together grow membership in service to our communities across BSCPHP business. The Director will lead in a highly matrixed environment across multiple internal business teams to provide strategic alignment, business planning, and effective execution of the business plans for all providers in their region for BSCPHP business as well as partner with all lines of business as they impact our Provider Network. Our leadership model is about developing great leaders at all levels and creating opportunities for our people to grow – personally, professionally, and financially. We are looking for leaders that are energized by creative and critical thinking, building and sustaining high-performing teams, getting results the right way, and fostering continuous learning. Responsibilities Your Work In this role, you will: Lead the Provider Relations team which serves as the primary liaison between BlueShield and Blue Shield Promise Health Plan and the contracted provider networks upholding transparency, integrity, and reliability in interactions with both internal and external stakeholders Oversee the management of provider concerns, including but not limited to contract interpretations, claims discrepancies, eligibility and capitation payment issues, credentialing challenges, service area changes, rate load corrections, retroactive member assignments, provider terminations, member moves and third-party disputes Develop and implement an operations engagement strategy that incorporates statewide Joint Operations Meetings, inclusive of Medi-Cal requirements, and includes interaction with provider leadership. The aim is to support provider satisfaction with Blue Shield, encourage provider wellness, and maintain operational performance in areas such as access to care, member experience, affordability, and sustainability Manage structured processes for claims disputes and appeals, driving research, root cause analysis, and corrective action plans to prevent recurring issues Deliver expert insight and guidance for strategic and operational initiatives impacting Provider Relations, driving effective execution of implementation tasks within the team's scope Provide effective and detailed thought leadership to inform the Blue Shield Provider Engagement Model working with the Performance Enablement Team Work collaboratively with Provider Partnerships and the Regional Medical Directors, along with other internal provider-facing partners, to execute an overall strategic engagement strategy Identify and implement process improvement as it pertains to provider operations, contract and regulatory compliance, efficient relationship management and other areas Establish operational Key Performance Indicators to assess the effectiveness and performance of the Provider Relations team. Define baseline metrics, set measurable targets, and drive achievement through ongoing process improvement Assess regulatory, government, or organizational mandates to ensure Blue Shield and Blue Shield Promise Health plans comply with all requirements. Work collaboratively with various departments to maintain internal compliance with regulations by leading workgroups and taskforces Build and lead a high-performing team that meets all operating goals, including cost of health care, clinical quality improvement, regulatory compliance, administrative costs and employee engagement Foster a culture of innovation and creativity to enable Blue Shield of California to meet changing market conditions and strategy Promote and model a collaborative and partnership-oriented culture by cultivating strong relationships with internal stakeholders to achieve collective success Qualifications Your Knowledge and Experience Requires a college degree or equivalent experience. Master’s degree is preferred Requires 10 years prior relevant experience in Provider Relations or healthcare network contracting Requires 6 years of management experience and must be comfortable operating in a matrixed/collaborative environment Minimum 5 years of direct Medicare and Medi-Cal experience with a Managed Care Organization (MCO) preferred Previous experience in management of process analysis and improvement Experience in the development of policies and procedures pertaining to Network Management Strong experience and orientation to the quadruple aim coupled with knowledge of markets, sales, operations, product development, network management, clinical operations, finance, regulatory issues and compliance Able to collaborate and work strategically in a team setting with various professional, technical, and administrative staff, integrating resources in a timely and organized manner Comprehensive knowledge of managed care risk contracts and the operational requirements involved in managing a provider network Outstanding verbal and written communication abilities, with demonstrated effectiveness when engaging executive leadership Demonstrated ability to build enduring, trustworthy relationships and effectively interact across all organizational levels, both internally and externally Ability to lead and manage significant culture change. Demonstrated experience with change and organization management; possess a performance driven management style Strong leadership skills, including excellent interpersonal, communications, problem solving and negotiating skills Ability to think strategically while at the same time drive operational performance Proven project management experience applying industry methodologies and practices Technologically savvy and able to utilize information systems and Office software effectively Proven ability to mentor and coach leaders in their respective teams

Requirements

Requires a college degree or equivalent experience.
Requires 10 years prior relevant experience in Provider Relations or healthcare network contracting
Requires 6 years of management experience and must be comfortable operating in a matrixed/collaborative environment
Minimum 5 years of direct Medicare and Medi-Cal experience with a Managed Care Organization (MCO) preferred
Previous experience in management of process analysis and improvement
Experience in the development of policies and procedures pertaining to Network Management
Strong experience and orientation to the quadruple aim coupled with knowledge of markets, sales, operations, product development, network management, clinical operations, finance, regulatory issues and compliance
Able to collaborate and work strategically in a team setting with various professional, technical, and administrative staff, integrating resources in a timely and organized manner
Comprehensive knowledge of managed care risk contracts and the operational requirements involved in managing a provider network
Outstanding verbal and written communication abilities, with demonstrated effectiveness when engaging executive leadership
Demonstrated ability to build enduring, trustworthy relationships and effectively interact across all organizational levels, both internally and externally
Ability to lead and manage significant culture change. Demonstrated experience with change and organization management; possess a performance driven management style
Strong leadership skills, including excellent interpersonal, communications, problem solving and negotiating skills
Ability to think strategically while at the same time drive operational performance
Proven project management experience applying industry methodologies and practices
Technologically savvy and able to utilize information systems and Office software effectively
Proven ability to mentor and coach leaders in their respective teams

Nice To Haves

Master’s degree is preferred
Minimum 5 years of direct Medicare and Medi-Cal experience with a Managed Care Organization (MCO) preferred

Responsibilities

Lead the Provider Relations team which serves as the primary liaison between BlueShield and Blue Shield Promise Health Plan and the contracted provider networks upholding transparency, integrity, and reliability in interactions with both internal and external stakeholders
Oversee the management of provider concerns, including but not limited to contract interpretations, claims discrepancies, eligibility and capitation payment issues, credentialing challenges, service area changes, rate load corrections, retroactive member assignments, provider terminations, member moves and third-party disputes
Develop and implement an operations engagement strategy that incorporates statewide Joint Operations Meetings, inclusive of Medi-Cal requirements, and includes interaction with provider leadership. The aim is to support provider satisfaction with Blue Shield, encourage provider wellness, and maintain operational performance in areas such as access to care, member experience, affordability, and sustainability
Manage structured processes for claims disputes and appeals, driving research, root cause analysis, and corrective action plans to prevent recurring issues
Deliver expert insight and guidance for strategic and operational initiatives impacting Provider Relations, driving effective execution of implementation tasks within the team's scope
Provide effective and detailed thought leadership to inform the Blue Shield Provider Engagement Model working with the Performance Enablement Team
Work collaboratively with Provider Partnerships and the Regional Medical Directors, along with other internal provider-facing partners, to execute an overall strategic engagement strategy
Identify and implement process improvement as it pertains to provider operations, contract and regulatory compliance, efficient relationship management and other areas
Establish operational Key Performance Indicators to assess the effectiveness and performance of the Provider Relations team. Define baseline metrics, set measurable targets, and drive achievement through ongoing process improvement
Assess regulatory, government, or organizational mandates to ensure Blue Shield and Blue Shield Promise Health plans comply with all requirements. Work collaboratively with various departments to maintain internal compliance with regulations by leading workgroups and taskforces
Build and lead a high-performing team that meets all operating goals, including cost of health care, clinical quality improvement, regulatory compliance, administrative costs and employee engagement
Foster a culture of innovation and creativity to enable Blue Shield of California to meet changing market conditions and strategy
Promote and model a collaborative and partnership-oriented culture by cultivating strong relationships with internal stakeholders to achieve collective success