Provider Relations Representative, Experienced

Blue Shield of California; California; Hybrid; USD 44,000 - 66,000; Full time

Job summary

Blue Shield of California seeks an Experienced Provider Relations Representative to maintain strong provider relationships across California. You will research provider inquiries, resolve escalated issues, and collaborate with cross-functional teams to support provider education and regulatory compliance.

This hybrid role requires a Bachelor's degree or equivalent, 3+ years of experience, and strong MS Office skills.

Qualifications

• Bachelor’s degree or High School Diploma/GED with 4 years of additional relevant experience.
• 3+ years of relevant experience preferred or required.
• Strong analytical, critical thinking, and problem-solving skills.
• Proficient in Microsoft Office applications (Excel, Word, Access, Outlook).

Responsibilities

• Research and resolve provider inquiries and escalated issues.
• Collaborate with cross-functional teams for provider education and regulatory compliance.
• Coordinate with IPA/Medical groups to ensure program adherence.
• Support process improvement initiatives and data-driven decision making.

Skills

Analytical thinking

Problem solving

MS Office proficiency

Healthcare terminology

Education

Bachelor’s degree or High School Diploma/GED with 4 years of additional relevant experience

3 years of prior relevant experience

Tools

Microsoft Office

Job description

Your Role

The Provider Service team is responsible for building and maintaining effective provider relationships with IPA/Medical groups, Providers and Hospitals. This entails services in the operational and compliance aspects of provider contracts and daily interaction with providers to effectively resolve service issues in a timely manner is a requirement. The Provider Relations Representative, Experienced will report to the Sr. Manager, Provider Services. In this role you will research and resolve provider inquiries, escalated issues, and operational challenges. Collaborate with cross-functional teams to support provider education, regulatory compliance, and process improvement initiatives. Exercise sound judgment in decision-making and seek guidance on highly complex issues when appropriate.

Job Description

The Provider Service team is responsible for building and maintaining effective provider relationships with IPA/Medical groups, Providers and Hospitals. This entails services in the operational and compliance aspects of provider contracts and daily interaction with providers to effectively resolve service issues in a timely manner is a requirement. The Provider Relations Representative, Experienced will report to the Sr. Manager, Provider Services. In this role you will research and resolve provider inquiries, escalated issues, and operational challenges. Collaborate with cross-functional teams to support provider education, regulatory compliance, and process improvement initiatives. Exercise sound judgment in decision-making and seek guidance on highly complex issues when appropriate.

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

• Implement strategies with providers to improve provider performance. Customize special education needs for providers as well as delivering strategic communications to assigned providers with good level of self-reliance.
• Coordinate escalated claim disputes and all necessary research timely and effectively which may require some reliance on their manager and senior level peers in setting action plans to analyze and resolve root cause.
• Implement or coordinate at least two geo-regional strategies with some support and guidance from manager.
• Coordinate data extracts and data analysis interpretation in preparation of reports aimed to determine necessity of rate increases to retain key PPO providers, with some support and guidance from peers or manager.
• Coordinate efforts to ensure BSC and its concentrated providers follow regulatory requirements.
• With some support from higher level PRCS, the Intermediate level is required to work closely with its assigned IPA/Medical Group to ensure it is compliant with Access and Availability requirements.
• Complete Transition and Disengagement Reports required by the Department of Manage Health care when IPAs/Medical Groups or Hospitals submit termination notices.
• Other duties as assigned.

Qualifications

Your Knowledge and Experience

• Bachelor’s degree or High School Diploma/GED and 4 years of additional relevant experience in lieu of a degree
• 3 years of prior relevant experience
• Strong analytical, critical thinking, and problem-solving skills with the ability to identify issues and develop effective solutions.
• Proficient in Microsoft Office applications, including Excel, Word, Access, and Outlook.
• Working knowledge of medical terminology and healthcare industry concepts.
• Experience working with Medi-Cal, Medicaid, or other government-sponsored healthcare programs preferred.
• Demonstrated ability to work independently, prioritize multiple assignments, and manage responsibilities with minimal supervision.
• Excellent organizational skills with strong attention to detail and accuracy.

Hybrid

This role requires employees to be in-office based on our hybrid workplace model, balancing purposeful in-person collaboration with flexibility. For most teams, this means coming into the office two days each week.

Employees living more than 50 miles from an office location will work with their manager to determine in-office time based on business need.

About Us

About Blue Shield of California

As of January 2025, Blue Shield of California became a subsidiary of Ascendiun. Ascendiun is a nonprofit corporate entity that is the parent to a family of organizations including Blue Shield of California and its subsidiary, Blue Shield of California Promise Health Plan; Altais, a clinical services company; and Stellarus, a company designed to scale healthcare solutions. Together, these organizations are referred to as the Ascendiun Family of Companies.

At Blue Shield of California, our mission is to create a healthcare system worthy of our family and friends and sustainably affordable. We are transforming health care in a way that genuinely serves our nonprofit mission by lowering costs, improving quality, and enhancing the member and physician experience.

To achieve our mission, we foster an environment where all employees can thrive and contribute fully to address the needs of the various communities we serve. We are committed to creating and maintaining a supportive workplace that upholds our values and advances our goals.

Blue Shield is a U.S. News Best Company to work for, a Deloitte U.S. Best Managed Company and a Top 100 Inspiring Workplace. We were recognized by Fair360 as a Top Regional Company, and one of the 50 most community-minded companies in the United States by Points of Light. Here at Blue Shield, we strive to make a positive change across our industry and communities – join us!

Our Values:

• Honest. We hold ourselves to the highest ethical and integrity standards. We build trust by doing what we say we're going to do and by acknowledging and correcting where we fall short.
• Human. We strive to listen and communicate effectively, showing empathy by understanding others' perspectives.
• Courageous. We stand up for what we believe in and are committed to the hard work necessary to achieve our ambitious goals.

Our Workplace Model

• For most teams, this means coming into the office two days per week.
• Employees living more than 50 miles from an office location, out of state employees, and employees in certain member-facing roles should work with their manager to determine in-office time based on business need.
• For employees with medical conditions that may impact their ability to work in-office, we are committed to engaging in an interactive process and providing reasonable accommodations to ensure their work environment is conducive to their success and well-being.

The Company reserves the right to require more presence in the office based on business needs, and requirements are subject to change with periodic reviews.

Physical Requirements:

Office Environment - roles involving part to full time schedule in Office Environment. Based in our physical offices and work from home office/deskwork - Activity level: Sedentary, frequency most of work day.

Equal Employment Opportunity:

External hires must pass a background check/drug screen. Qualified applicants with arrest records and/or conviction records will be considered for employment in a manner consistent with Federal, State and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regards to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or disability status and any other classification protected by Federal, State and local laws.

JOB INFO

• Job Identification : 20262084
• Job Category : Provider Network
• Posting Date : 2026-10-21T16:21:25+00:00
• Job Schedule : Full time
• Long Beach, CA, United States
• San Diego, CA, United States
• Woodland Hills, CA, United States
• Pay Range for California : $32.03 to $48.04
• Pay Range for Bay Area : $36.10 to $54.16
• Note : Please note that this range represents the pay range for this and many other positions at Blue Shield that fall into this pay grade. Blue Shield salaries are based on a variety of factors, including the candidate experience, location (California, Bay Area, or outside California), and current employee salaries for similar roles.
• Role can be filled by a candidate requiring sponsorship : No