Provider Solutions Consultant

This is a fully remote position, open to applicants in Missouri.

📋 Description

• Collaborates closely with the Provider Payment Solutions team and Blue KC Account Executives and Account Managers across various business lines to assess and monitor the service performance of Blue KC’s providers; suggests action plans to address provider service challenges.

• Proactively establishes the overall direction, roadmap, and improvement initiatives for Provider Solutions functions that are essential to Blue KC's operations.

• Develops and employs tools to proactively assess performance, enabling timely recommendations and actions that directly influence outcomes.

• Responsible for managing key Provider Relationships, particularly regarding claims that are not processed correctly.

• Identifies, triages, and prioritizes issues with contributions from cross-functional partners.

• Facilitates solutions for production and payment issues through a comprehensive understanding of systems and their functionalities.

• Regularly performs research and analysis on provider service challenges using performance reports and service data sets; Evaluates issues to identify root causes and impact areas, making recommendations for process enhancements.

• Oversees action plans to address service issues which may lead to new or revised corporate and departmental policies, procedures, and workflows.

• Communicates effectively with team members and leadership.

• Engages as necessary in the Provider Service Management Team (a cross-functional team aimed at discussing, prioritizing, and resolving provider service issues).

• Coordinates and facilitates small team initiatives within and across departments.

• Cultivates proactive and positive relationships with other departments within Blue KC to address provider concerns.

• Manages collaborative provider relationships by leading meetings to resolve intricate issues and reviewing claim action logs.

• Responsible for submitting monthly provider service scorecards within deadlines and conducting data integrity audits to ensure scorecard data is accurate and reliable.

• Monitors, analyzes, and communicates key metrics associated with specific issues/projects.

• Independently conducts analysis and leads discussions regarding the interplay of clinical reimbursement and benefit strategies for complex, cross-functional provider payment challenges.

⛳️ Requirements

• Bachelor’s degree in Clinical Sciences or Business Administration, or a combination of education and experience that provides the knowledge, skills, and abilities required for the job.

• 5 – 7 years of professional experience in operational and/or analytic processes, preferably in the healthcare sector or managed care payer.

• Strong knowledge of Blue KC's core systems (including, but not limited to, Facets, ClaimsXten, NetworX).

• Solid understanding of claims, reimbursement, and benefit structures.

• Excellent verbal and written communication skills.

• Proficient in Microsoft Word, Excel, Access, and PowerPoint, or comparable PC-based software.

• Demonstrated organizational, planning, and administrative capabilities.

• Ability to operate effectively under pressure with limited resources, competing priorities, and defined project timelines.

• Self-motivated; capable of working with minimal supervision.

• 7 years of professional experience in operational and/or analytic processes, preferably within the healthcare sector or managed care payer (preferred).

🏝️ Benefits

• Highly competitive total rewards package, which includes comprehensive medical, dental, and vision benefits along with a 401(k) plan that includes contributions from both the employee and the employer.

• Annual incentive bonus plan contingent on the company's achievement of goals.

• Time off from work including paid holidays, paid time off, and volunteer time off.

• Opportunities for professional development, mentorship, and a tuition reimbursement program.

• Paid parental leave and adoption leave with financial assistance for adoption.

• Employee discount program.