Provider Relations Representative III (Hybrid)

Resp & Qualifications

PURPOSE: 

This role enables a seamless provider experience. This role serves as a primary liaison with stakeholders within Health Services and across the company to provide 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. The incumbent acts as a ""go-to"" for other team members, providing coaching and mentoring to other team members. Role models and share best practices with other team members related to all aspects of the Provider Relations Representative role.

We are looking for an experienced professional in the greater Baltimore/Washington metropolitan area who is willing and able to work in a hybrid model. The incumbent will be expected to work a portion of their week from home and a portion of their week at a CareFirst location based on business needs and work activities/deliverables that week.

ESSENTIAL FUNCTIONS:

• TRAINING AND EDUCATION: Provides ongoing and targeted training and education to our 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.
• TEAM LEADERSHIP:  Recognized as a go-to person in the department. Successfully mentors and supports other Provider Relations Representatives as part of the onboarding process and proactively on an ongoing basis. Shares program knowledge and experience in training sessions, and other meetings. 
• ISSUE RESOLUTION: Acts as a subject matter expert to many departments across the organization, providing research, resolution, and support for escalated service-related issues, using expertise and connections with multiple parties across CareFirst. Identifies and resolves root causes, 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.
• 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.
• PROJECT MANAGEMENT: Leads 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. Takes an active role in designing, monitoring, and improving processes the department owns. Identifies key drivers, other trends, and make recommendations that will result in improved outcomes in business operations and provider satisfaction.
  
   

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: 7 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.
• 2 years' experience within the CareFirst Provider Relations department. 

Knowledge, Skills and Abilities (KSAs)

• Knowledge of provider billing and coding mechanisms, including special pricing, medical terminology, CPT coding and CMS-1500 or CMS UB-04 claim formats.
• Thorough knowledge of managed care industry legislated and regulated requirements, health care financial matters and third-party payment methodologies.
• Understanding of contractual documents and ability to effectively communicate terms to providers.
• Ability to effectively use Microsoft Excel, Microsoft Access, Microsoft PowerPoint and Microsoft Word.
• Written and verbal communications skills including exceptional customer service skills.
• Problem-solving ability, critical thinking, and analytical skills.
• Ability to effectively navigate, de-escalate, and resolve interpersonal conflict that can arise in client-facing roles.
• 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.
• Experience and demonstrated ability to train, coach and mentor other team members within the core functional unit and in other areas of Health Services.
• 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.

Salary Range: $60,696 - $120,549


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

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 responsibilites 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).

Department

Provider Relations and Education

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.

Where To Apply

Please visit our website to apply: www.carefirst.com/careers

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 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.

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