Provider Relations Consultant

BlueCross BlueShield of South Carolina•Columbia, SC

2d•Onsite

About The Position

Establishes and maintains positive relationships with network hospitals, physician and/or dental practices, and their representatives. Serves as point of contact for provider problems/issues. Responds to non-routine or difficult problems/issues related to network contracts, reimbursement methodologies, benefit structure, medical policies, administrative policies, etc. Determines underlying cause(s) of problems and recommends changes to alleviate problems/issues. Coordinates/conducts meeting for problem resolution. Provides management with feedback on problems/issues. Logistics: BlueCross BlueShield of South Carolina - About Us | BlueCross BlueShield of South Carolina Location: This is a full-time position located at 4101 Percival Rd. Columbia, SC 29229. The hours for this position are 8:30AM - 5:00PM. These hours will vary at times because this position will require traveling within the state of South Carolina 3 -5 days a week, which will include some weekday and weekend overnight stays. Must have reliable transportation. What You’ll Do: Serves as point of contact for provider problems/issues. Responds to non-routine or difficult problems/issues related to network contracts, reimbursement methodologies, benefit structure, medical policies, administrative policies, etc. Determines underlying cause(s) of problems and recommends changes to alleviate problems/issues. Coordinates/conducts meeting for problem resolution. Provides management with feedback on problems/issues. Creates educational materials (webinars, brochures, etc.) for providers. Educates providers on all lines of business such as Medicare Advantage, BlueChoice, FEP, State, as well as our corporate products, including the Exchanges. Explains coverage, website navigation, utilization statistics, and documentation requirements by using written advisories, reports, letters, bulletins, telephone contacts and in person visits. Documents all provider contacts and communications in the provider education database. Conducts training in the following areas: electronic filing, reducing duplicate claims filings, incorrect claims filing, contract requirements, and reimbursements. Conducts workshops and speaks at conferences, meetings, conventions, etc. as requested by hospitals, physician and/or dental practice groups. Prepares/submits various reports to management.

Requirements

Bachelor's Degree or Equivalency: 4 years job related work experience or Associate's and 2 years job related work experience.
5 years of healthcare, medical affairs, provider network, claims management, or combination of these. 2 of the 5 years must have been with direct health plan/payer programs.
Knowledge/understanding of automated medical management systems and claims processing systems.
Ability to work independently, prioritize effectively, and make sound decisions.
Good judgment skills.
Demonstrated customer service, organizational, and presentation skills.
Ability to persuade, negotiate, or influence others.
Analytical or critical thinking skills.
Basic business math and knowledge of mathematical/statistical concepts.
Ability to handle confidential or sensitive information with discretion.
Ability to lead and motivate employees.
Microsoft Office.

Nice To Haves

Bachelor's degree-in Business Administration, Business Management, Healthcare Administration, Marketing, or other job-related field.
Demonstrated strong knowledge of claims processing and the AMMS system.
Proven research and analytical skills with the ability to identify root causes and solutions.
Effective collaborator with the ability to work cross‑functionally and build productive relationships.
Strong verbal communication and public speaking skills, with experience presenting to diverse audiences.
Experience delivering training and education on new and existing policies, procedures, and workflows.
Ability to professionally de‑escalate complex situations and influence outcomes through persuasion and diplomacy.
Strong critical thinking skills with the ability to develop innovative, practical solutions.

Responsibilities

Serves as point of contact for provider problems/issues.
Responds to non-routine or difficult problems/issues related to network contracts, reimbursement methodologies, benefit structure, medical policies, administrative policies, etc.
Determines underlying cause(s) of problems and recommends changes to alleviate problems/issues.
Coordinates/conducts meeting for problem resolution.
Provides management with feedback on problems/issues.
Creates educational materials (webinars, brochures, etc.) for providers.
Educates providers on all lines of business such as Medicare Advantage, BlueChoice, FEP, State, as well as our corporate products, including the Exchanges.
Explains coverage, website navigation, utilization statistics, and documentation requirements by using written advisories, reports, letters, bulletins, telephone contacts and in person visits.
Documents all provider contacts and communications in the provider education database.
Conducts training in the following areas: electronic filing, reducing duplicate claims filings, incorrect claims filing, contract requirements, and reimbursements.
Conducts workshops and speaks at conferences, meetings, conventions, etc. as requested by hospitals, physician and/or dental practice groups.
Prepares/submits various reports to management.