Provider Solutions Consultant

• Highly competitive total rewards package, including comprehensive medical, dental and vision benefits as well as a 401(k) plan that both the employee and employer contribute
• Annual incentive bonus plan based on company achievement of goals
• Time away from work including paid holidays, paid time off and volunteer time off
• Professional development courses, mentorship opportunities, and tuition reimbursement program
• Paid parental leave and adoption leave with adoption financial assistance
• Employee discount program

• High level of Critical Thinking, ability to Think Outside of the Box to drive Resolution
• Proactively defines overall direction, roadmap and improvement actions for Provider Solutions functions that are core to the BlueKC business
• Create and utilize tools to proactively evaluate performance so that actions can be recommended and taken to directly impact the results in a timely manner.
• Accountable for key Provider Relationships especially as it relates to claims not paying correctly
• Identify, triage, and prioritize issues with input from cross-functional partners.
• Drives solutions of production and payment issues based on an in-depth understanding of systems and system functionality. Regularly conduct research and analysis of provider service issues based on performance reports and service data sets; Assess issues to determine root causes and issue impact areas and make process improvement recommendations.
• Manage action plans to resolve service issues which could lead to new or updates to corporate and departmental policies, procedures, and workflows.
• Communicates effectively with team members and team leadership
• Participate as needed in Provider Service Management Team (cross-functional team designed to discuss, prioritize and resolve provider service issues).
• Coordinate and facilitate small team efforts within and across departments.
• Develop proactive and positive working relationships with other departments within Blue KC to resolve provider issues.
• Manage collaborative provider relationships by leading meetings with provider to resolve complex issues and review of claim action logs
• Responsible for completing monthly provider service scorecards within timelines and performance of data integrity audits to ensure scorecard data is reasonable and accurate.
• Tracks, analyzes and communicates key metrics related to specific issues/projects
• Independently provides analysis and leads discussion specific to the interaction of clinical reimbursement and benefit strategies for complex, cross-functional provider payment issues.

Minimum Qualifications

• Bachelor's degree in Clinical Sciences or Business Administration or any combination of education and experience providing the types and level of knowledge, skills and ability required by the job.
• 5 - 7 years of professional experience working with operational and/or analytic processes, preferably within the healthcare industry or managed care payor
• Strong understanding of Blue KC core systems (including but not limited to Facets, ClaimsXten, NetworX)
• Strong understanding of claims, reimbursement, and benefit structures
• Strong professional communicator in both oral and written forms
• Strong knowledge and skills using Microsoft Word, Excel, Access, and PowerPoint, or similar PC-based software.
• Demonstrated organizational, planning, and administrative skills.
• Ability to work under pressure with limited resources, competing priorities and specific project timelines.
• Self-starter; ability to work with minimal direction

Preferred Qualifications

• 7 years of professional experience working with operational and/or analytic processes, preferably within the healthcare industry or managed care payor
• Extensive understanding of Blue KC Claims, Reimbursement and Benefit Structures

Blue Cross and Blue Shield of Kansas City is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to, among other things, race, color, religion, sex, sexual orientation, gender identity, national origin, age, status as a protected veteran, or disability.