What We’re Looking For: We're seeking a driven and experienced individual to oversee provider trend issue resolution. Your expertise will guide our team in implementing new reimbursement methodologies and managing the Provider Administration Manual and Provider Dispute Resolution Procedure (PDRP) appeals.

What You'll Do:

Leadership: Establish and manage processes for staff to prioritize and resolve provider issues, supporting the PDRP.Expertise: Act as a subject matter expert, fostering collaboration across enterprise teams on new reimbursement methodology proposals and issue resolution.Project Management: Coordinate and oversee significant provider reimbursement issue resolution projects, incorporating input from various enterprise areas.Appeals Management: Handle all aspects of PDRP appeals, ensuring BlueCross BlueShield of Tennessee (BCBST) meets all obligations and promotes provider satisfaction.Communication: Monitor and communicate significant provider terminations and enterprise-wide responses.

Differentiators and Important Details:

Impactful Role: This position plays a critical role in maintaining compliance with organizational business goals and regulations while ensuring provider satisfaction.Collaborative Environment: You'll build bridges among enterprise teams, ensuring new reimbursement methodologies are programmable, consistent, and compliant.Comprehensive Oversight: Manage provider reimbursement issue resolution projects and PDRP appeals, directly contributing to the success and reputation of BCBST.

*Please note that while this is a remote role, frequent visits to Chattanooga will be necessary for this opening.

Job Responsibilities

Manages and establishes processes and practices for staff responsible for the prioritization and provision of provider issue resolutions and support of the PDRP.Serves as subject matter expert and builds bridges among enterprise teams regarding new reimbursement methodology proposals and issue resolution ensuring they are programmable, consistent, and compliant with organizational business goals and regulations.Coordinates and oversees significant provider reimbursement issue resolution project management incorporating other areas of the enterprise as needed.Manages all aspects of the PDRP Appeals to ensure BCBST meets all obligations and promotes provider satisfaction.Communicates and monitors significant provider terminations and enterprise-wide responses.

Job Qualifications

Education

Bachelor's Degree or equivalent work experience required. Equivalent experience is defined as 4 years of professional work experience in a corporate environment.

Experience

7 years - Progressive experience in business strategic planning, project/program-level management with demonstrated negotiation skills across multiple divisions and levels of management required, preferably in provider-focused initiatives.3 years - Management and/or leadership experience required

Skills/Certifications 

Ability to work independently with minimal supervision or function in a team environment sharing responsibility, roles and accountability.Proficient in Microsoft Office (Outlook, Word, Excel, Access and PowerPoint)Must be a team player, be organized and have the ability to handle multiple projectsExcellent oral and written communication skillsStrong interpersonal and organizational skillsAbility to lead and motivate cross-functional, interdisciplinary teams to achieve tactical and strategic goals.Demonstrated knowledge and experience with a wide range of provider contacting arrangements, performance-based reimbursement strategies, network adequacy and reimbursement models.

Number of Openings Available:

1

Worker Type:

Employee

Company:

BCBST BlueCross BlueShield of Tennessee, Inc.

Applying for this job indicates your acknowledgement and understanding of the following statements:

BCBST is an Equal Opportunity employer (EEO), and all employees and applicants will be entitled to equal employment opportunities when employment decisions are made. BCBST will take affirmative action to recruit, hire, train and promote individuals in all job classifications without regard to race, religion, color, age, sex, national origin, citizenship, pregnancy, veteran status, sexual orientation, physical or mental disability, gender identity, or any other characteristic protected by applicable law.

Further information regarding BCBST's EEO Policies/Notices may be found by reviewing the following page:

BCBST's EEO Policies/Notices

BlueCross BlueShield of Tennessee is not accepting unsolicited assistance from search firms for this employment opportunity. All resumes submitted by search firms to any employee at BlueCross BlueShield of Tennessee via-email, the Internet or any other method without a valid, written Direct Placement Agreement in place for this position from BlueCross BlueShield of Tennessee HR/Talent Acquisition will not be considered. No fee will be paid in the event the applicant is hired by BlueCross BlueShield of Tennessee as a result of the referral or through other means.

Tobacco-Free Hiring Statement

To further our mission of peace of mind through better health, effective 2017, BlueCross BlueShield of Tennessee and its subsidiaries no longer hire individuals who use tobacco or nicotine products (including but not limited to cigarettes, cigars, pipe tobacco, snuff, chewing tobacco, gum, patch, lozenges and electronic or smokeless cigarettes) in any form in Tennessee and where state law permits. A tobacco or nicotine free hiring practice is part of an effort to combat serious diseases, as well as to promote health and wellness for our employees and our community. All offers of employment will be contingent upon passing a background check which includes an illegal drug and tobacco/nicotine test.  An individual whose post offer screening result is positive for illegal drugs or tobacco/nicotine  and/or whose background check is verified to be unsatisfactory, will be disqualified from employment, the job offer will be withdrawn, and they may be disqualified from applying for employment for six (6) months from the date of the post offer screening results.

Resources to help individuals discontinue the use of tobacco/nicotine products include smokefree.gov or 1-800-QUIT-NOW.