Provider Relations Representative, Experienced

Your Role 

The Provider Services team is responsible for building and maintaining effective provider relationships with IPA/Medical groups, Providers and Hospitals. The Provider Relations Representative, Experienced will report to the Director, Provider Services – Relations. In this role you will play a key part in ensuring the success of the California Advancing and Innovating Medi-Cal (CalAIM) program by supporting provider participation and engagement.  This position offers an opportunity to make a meaningful difference in the healthcare system by supporting providers in delivering coordinated, high-quality care to Medi-Cal members. Through your contributions, you will help drive program success, improve provider experiences, and support initiatives that promote health equity and better outcomes across the communities.

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 

In this role, you will: 

• 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 CalAim providers, with some support and guidance from peers or director

• Coordinate efforts to ensure the Company 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 CalAim providers to ensure it is compliant with Access and Availability requirements

• 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 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. 

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.

Please click here for further physical requirement detail. 

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.