Provider Relations Representative I (Hybrid)

CareFirst BlueCross BlueShield; Baltimore (MD); On-site; USD 49,000 - 98,000; Full time

Job summary

CareFirst BlueCross BlueShield in Baltimore, MD is seeking a Provider Relations Specialist to serve as the primary liaison for in-network providers across Health Services and the company. The role emphasizes building strong provider relationships, delivering ongoing education, and resolving issues to support member care and corporate goals.

Key duties include relationship management, training, issue resolution, and project management to improve provider experiences and performance metrics.

Qualifications

• Education level as stated: Associate's degree or equivalent; 2 years of related experience if no Associate's degree.
• 2 years experience with CareFirst computer systems, networks, products, policies and provider processes.

Responsibilities

• RELATIONSHIP MANAGEMENT: Establishes and maintains provider relationships and drives favorable outcomes.
• TRAINING AND EDUCATION: Provides ongoing training to providers on portal use and processes.
• ISSUE RESOLUTION: Researches and resolves escalated service issues with internal partners.
• PROJECT MANAGEMENT: Supports network projects to mitigate risk and support initiatives.

Skills

Relationship management

Training and education

Issue resolution

Project management

Microsoft Office

Education

Associate's degree or equivalent experience

Bachelor's degree in business, healthcare administration or related

Tools

Microsoft Excel

Microsoft Access

Microsoft PowerPoint

Microsoft Word

Job description

PURPOSE:

This role enables a seamless provider experience serving as a primary liaison with stakeholders within Health Services and across the company. Provides communication, education, issue/dispute resolution and support of managing all of CareFirst's contracted in-network providers including independent professional practices, health systems, hospitals, and ancillary providers across all lines of business.

Resp & Qualifications

This role enables a seamless provider experience serving as a primary liaison with stakeholders within Health Services and across the company. Provides communication, education, issue/dispute resolution and support of managing all of CareFirst's contracted in-network providers including independent professional practices, health systems, hospitals, and ancillary providers across all lines of business.

Essential Functions

• RELATIONSHIP MANAGEMENT: Establishes and maintains relationships with providers and key stakeholders, by ensuring regular communications and timely problem resolution. Leverages provider relationships to drive and influence provider behavior towards favorable outcomes in support of corporate initiatives and positive member interactions.
• TRAINING AND EDUCATION: Provides ongoing and targeted training and education to provider community ensuring they can successfully utilize electronic tools, navigate provider portal, follow established processes and procedures. Partners with Provider Training and Education Department to educate providers ensuring they are engaged in the value of our programs in support of positive member interactions.
• ISSUE RESOLUTION: Provides research, resolution and support for escalated service-related issues, using expertise and coordinates between multiple parties across CareFirst. Identifies and resolves root cause, either independently or through formal resolution processes. Offers timely response to providers, management, and other internal customers via virtual or face-to-face visit, correspondence, e-mail, and/or phone as appropriate.
• PROJECT MANAGEMENT: Supports network projects and outreach initiatives that must be special handled by Provider Relations in order to mitigate risk to CareFirst, supplement existing technology, maintain critical operations, support corporate initiatives including but not limited to provider experience scores, STAR ratings, HEDIS measures, and CAHPS program.

Qualifications

• Education Level: Associate's Degree OR in lieu of an Associate degree, an additional 2 years of relevant work experience is required in addition to the required work experience.
• Experience: 2 years experience with CareFirst computer systems (or comparable technology platforms), networks, products, policies, and procedures, including experience with providers, training, customer service, and claims processing.

Preferred Qualifications

• Bachelor's Degree in business, healthcare administration or related industry.

Knowledge, Skills And Abilities (KSAs)

• Working knowledge of provider billing and coding mechanisms, including special pricing, medical terminology, CPT coding and CMS-1500 or CMS UB -04 claim formats.
• Knowledge of managed care industry legislated and regulated requirements, health care financial matters and third-party payment methodologies.
• Previous experience working either at CareFirst, an insurance plan, a hospital or a physician hospital organization (PHO).
• Understanding of contractual documents and ability to effectively communicate terms to providers.
• Ability to work effectively using Microsoft Excel, Microsoft Access, Microsoft PowerPoint and Microsoft Word.
• Ability to determine priorities and meet deadlines. Self-motivation, and the ability to work independently and manage competing priorities in order to meet the needs of varying stakeholders and comply with varying mandated deadlines.
• Written and verbal communication including excellent customer service skills.
• Problem-solving ability, critical thinking, and analytical skills.
• Ability to help navigate, de-escalate, and resolve interpersonal conflict that can arise in client-facing roles.
• Effective presentation skills with ability to facilitate meetings, presenting information, and public speaking.
• Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence. Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.

Travel Requirements

• Estimate Amount: 50% Frequent travel to provider offices, hospitals, medical offices.

Salary Range

• $49,464 - $98,241

Salary Range Disclaimer

The disclosed range estimate has not been adjusted for the applicable geographic differential associated with the location at which the work is being performed. This compensation range is specific and considers factors such as (but not limited to) the scope and responsibilities of the position, the candidate's work experience, education/training, internal peer equity, and market and business consideration. It is not typical for an individual to be hired at the top of the range, as compensation decisions depend on each case's facts and circumstances, including but not limited to experience, internal equity, and location. In addition to your compensation, CareFirst offers a comprehensive benefits package, various incentive programs/plans, and 401k contribution programs/plans (all benefits/incentives are subject to eligibility requirements).

Equal Employment Opportunity

CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.

Federal Disc/Physical Demand

Note: The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs.

Physical Demands

The associate is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The associate must frequently talk and hear. Weights up to 25 pounds are occasionally lifted.

Sponsorship in US

Must be eligible to work in the U.S. without Sponsorship