Provider Relations Representative HYBRID

hcsc; Springfield (IL); Hybrid; USD 70,000 - 100,000; Full time

Job summary

HCSC is seeking a Provider Relations role to manage contracting, credentialing, and ongoing data maintenance for a broad provider network. The position emphasizes building strong provider relations, data quality, and cross-department collaboration across all lines of business in a hybrid work setting.

The role requires a Bachelor's degree and 3+ years in managed care (5+ years acceptable), with travel for provider engagement and training responsibilities. Relocation is not offered.

Qualifications

• Bachelor's Degree or equivalent managed care experience.
• 3+ years in managed care; 5+ years acceptable.
• Excellent communication, presentation, and problem-solving skills.

Responsibilities

• Establishes and maintains relationships with Blue Cross contracted providers.
• Escalate provider issues and coordinate claims resolution.
• Maintain knowledge of provider contracts across all lines of business.
• Lead internal/external seminars and prepare PowerPoint decks.
• Train and educate contracted providers on processes and systems.
• Collaborate across departments to improve provider relations.

Skills

Interpersonal skills

Analytical skills

Presentation skills

Communication skills

Healthcare industry knowledge

Ability to travel

Contracts knowledge

Claims knowledge

Organizational skills

PC proficiency

Education

Bachelor's Degree (related field)

IAMHP affiliation

Tools

Excel

PowerPoint

Salesforce

Provider management systems

Job description

At HCSC, our employees are the cornerstone of our business and the foundation to our success. We empower employees with curated development plans that foster growth and promote rewarding, fulfilling careers.

Join HCSC and be part of a purpose-driven company that will invest in your professional development.

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 role is HYBRID/FLEX and requires in-office visibility three days per week, working from home the other two days. 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.
• Excellent facilitation, presentation and research 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
• Affiliation with IAMHP (Illinois Association of Medicaid Health Plans)
• Experience working with government agencies, legislative and advocacy groups

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 prof