Blue Shield of California

Job Description

Your Role

The PPO Professional Provider Contracting team manages our PPO and Medi-Cal network to maintain network adequacy by contract negotiation, recruitment and building/maintaining professional relationships. The Provider Contracting Specialist, Senior will report to the Provider Contracting Manager. In this role you will ensure the acquisition, servicing and performance of Physicians/Medical Groups and other Specialty Network Providers to the Blue Shield of California contracted network. Support attainment of department goals under the leadership of the Director of Provider Contracting and/or Provider Contracting Manager and ensures alignment of these goals with the company’s strategic priorities. Supports review and modification of contracting and cost of health care savings strategies in anticipation of, and in response to, shifts in provider and competitor negotiation approaches. Research opportunities within the assigned local market (i.e., network expansion opportunities, utilization, or unit cost excesses, etc.) and assesses market trends to drive initiatives which enhance company’s market position. Other duties as assigned.

Responsibilities

Your Work

In this role, you will:

• Specializing in ancillary contracting for networks that include Home Health, Hospice, and Palliative Care with the knowledge of industry guidelines for all lines of business Commercial, Medicare, and Medi-Cal.
• Facilitate ancillary contracting from an end-to-end process by evaluating the business needs and capacity to meet obligations using strategic insight.
• Management of network adequacy through procurement of new contracts in targeted regions by solicitation.
• Review contract language and terms within company procedures that includes the editing and drafting of agreements with contract redlining.
• Conduct strategic analysis of financial modeling for contract negotiations involving rate proposals to ensure alignment with organizational goals, budgetary constraints, and compliance with corporate policy and procedures.
• Maintain existing networks and relationships through negotiation renewals within a targeted budget.
• Coordinate and engage with internal business units that may include Legal Department, Model Contracts, Utilization Management, Sales, Claims, and Contracting Department to assist with ancillary contracting and enterprise needs.
• Adhere to department regulatory requests and corrective action plans from DMHC, DHCS, and CMS to ensure Health Plan compliance of existing contracted networks.
• Serve as the escalation point of contact within a contracted network, managing complex issues related to claims, member access to care, provider disputes, and cross functional internal requests.
• Support the maintenance of demographic data within the network that encompasses credentialing of service locations including address updates, contract terminations, and banking EFT validations

Qualifications

Your Knowledge and Experience

• Requires a bachelor's degree in business, healthcare policy, public health or related field, or equivalent experience
• Requires at least 5 years provider contracting / negotiation/ provider relations experience including experience managing complex negotiations
• Strong analytical and problem-solving skills
• Excellent interpersonal, oral and written communication skills
• Health care industry/provider network knowledge including data analysis, understanding of provider contract language including provider reimbursement methodologies etc.
• Ability to develop, organize, analyze, and implement processes and procedures
• Broad business skills including analysis of strategic alternatives, financial impact analysis and sales experience/exposure

ABOUT US

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.

Our Workplace Model:

At Blue Shield of California and the Ascendiun Family of Companies, we believe in fostering a workplace environment that balances purposeful in-person collaboration with flexibility. As we continue to evolve our workplace model, our focus remains on creating spaces where our people can connect with purpose – whether working in the office or through a hybrid approach – by providing clear expectations while respecting the diverse needs of our workforce.

Two Ways of Working:

• Hybrid (Default): Work from a business unit-approved office at least two (2) times per month (for roles below Director-level) or once per week (for Director-level roles and above). Exceptions:

o Member-facing and approved out-of-state roles remain remote.

o Employees living more than 50 miles from their assigned offices are expected to work with their managers on a plan for periodic office visits.

o For employees with medical conditions that may impact their ability to work in-office, we are committed to engaging in an interactive process and providing reasonable accommodations to ensure their work environment is conducive to their success and well-being.

• On-Site: Work from a business unit-approved office an average of four (4) or more days a week.

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.

Pay Range for California $89100.00 to $133650.00 Pay Range for Bay Area $100440.00 to $150660.00 Please note that this range represents the pay range for this and many other positions at Blue Shield that fall into this pay grade. Blue Shield salaries are based on a variety of factors, including the candidate experience, location (California, Bay Area, or outside California), and current employee salaries for similar roles.