Provider Solutions Consultant

Blue Cross and Blue Shield of Kansas City • Work At Home - Missouri, MO

9d

About The Position

The Provider Payment Solutions Consultant (PSC) works in partnership with the 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. The PSC recommends action plans to resolve provider service issues. This role requires a high level of critical thinking and the ability to think outside of the box to drive resolution. The PSC proactively defines the overall direction, roadmap, and improvement actions for Provider Solutions functions that are core to the BlueKC business. They create and utilize tools to proactively evaluate performance so that actions can be recommended and taken to directly impact results in a timely manner. The PSC is accountable for key Provider Relationships, especially as it relates to claims not paying correctly. They identify, triage, and prioritize issues with input from cross-functional partners and drive solutions for production and payment issues based on an in-depth understanding of systems and system functionality. The role involves regularly conducting research and analysis of provider service issues based on performance reports and service data sets, assessing issues to determine root causes and impact areas, and making process improvement recommendations. The PSC manages action plans to resolve service issues, which could lead to new or updated corporate and departmental policies, procedures, and workflows. They communicate effectively with team members and leadership, participate as needed in the Provider Service Management Team (a cross-functional team designed to discuss, prioritize, and resolve provider service issues), and coordinate/facilitate small team efforts within and across departments. Developing proactive and positive working relationships with other departments within Blue KC is crucial for resolving provider issues. The PSC manages collaborative provider relationships by leading meetings with providers to resolve complex issues and review claim action logs. They are responsible for completing monthly provider service scorecards within timelines and performing data integrity audits to ensure scorecard data is reasonable and accurate. The role also involves tracking, analyzing, and communicating key metrics related to specific issues/projects and independently providing analysis and leading discussions specific to the interaction of clinical reimbursement and benefit strategies for complex, cross-functional provider payment issues.

Requirements

• 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.
• Strong knowledge and skills using Microsoft Word, Excel, Access, and PowerPoint, or similar PC-based software.
• 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.

Nice To Haves

• 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.

Responsibilities

• Evaluate and monitor Blue KC’s provider service performance.
• Recommend action plans to resolve provider service issues.
• Define overall direction, roadmap, and improvement actions for Provider Solutions functions.
• Create and utilize tools to proactively evaluate performance.
• Accountable for key Provider Relationships, especially as it relates to claims not paying correctly.
• Identify, triage, and prioritize issues with input from cross-functional partners.
• Drive solutions of production and payment issues based on an in-depth understanding of systems and system functionality.
• Conduct research and analysis of provider service issues based on performance reports and service data sets.
• Assess issues to determine root causes and issue impact areas and make process improvement recommendations.
• Manage action plans to resolve service issues.
• Communicate effectively with team members and team leadership.
• Participate as needed in the Provider Service Management Team.
• Coordinate and facilitate small team efforts within and across departments.
• Develop proactive and positive working relationships with other departments within Blue KC.
• Manage collaborative provider relationships by leading meetings with providers to resolve complex issues and review of claim action logs.
• Complete monthly provider service scorecards within timelines.
• Perform data integrity audits to ensure scorecard data is reasonable and accurate.
• Track, analyze, and communicate key metrics related to specific issues/projects.
• Independently provide analysis and lead discussion specific to the interaction of clinical reimbursement and benefit strategies for complex, cross-functional provider payment issues.

Benefits

• Highly competitive total rewards package, including comprehensive medical, dental and vision benefits as well as a 401(k) plan that both the employee and employer contribute
• Annual incentive bonus plan based on company achievement of goals
• Time away from work including paid holidays, paid time off and volunteer time off
• Professional development courses, mentorship opportunities, and tuition reimbursement program
• Paid parental leave and adoption leave with adoption financial assistance
• Employee discount program

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level