Provider Network Consultant

Bachelor’s degree in health care or business administration or a minimum of 4 years work experience in a managed care environment.
Minimum of 2 years of health care administration experience in clinical and financial settings, with direct provider communication experience.
Effective interpersonal, analytical, presentation and communication skills.
Knowledge of the health care industry and BCBSIL private business.
Ability and willingness to travel within assigned areas for responsibility, including overnight stays.
Extensive knowledge of contracts, applications, and products.
Demonstrated proficiency in provider reimbursement methods.
Working knowledge of claims processing systems.
Effective organizational and planning skills.
Ability to take initiative and work independently.
Demonstrated ability to meet deadlines and work well under pressure.
Working knowledge of software, including Microsoft Office.

Developing and maintaining cooperative working relationships with the contracting provider community.
Educating, training, researching problems, and identifying trends.
Evaluating providers to ensure contractual and financial requirements are adhered to and performed.
Ability and willingness to travel, including overnight stays.

Knowledge of ICD-10, CPT, HCPCS and revenue codes
COB (Coordination of Benefits) and overpayment knowledge
Familiar with Medicare, Medicaid and Commercial payer rules
Experience identifying and resolving complex claims issues and trends
Proven ability to analyze root cause and recommend improvements
Experience supporting cross functional teams which include Provider Relations, Customer Service and Claims
Strong verbal and written communication skills, especially in claims logic
The ability to train staff on claims processes and workflows