Manager, Operations

Provider Dispute Resolution Operations Manager

The Provider Dispute Resolution (PDR) Operations team manages and processes provider disputes across the Commercial, Medi-Cal and Medicare lines of business and the No Surprise Billing(NSB) process. The team also partners with an offshore vendor to complete provider disputes and other strategic projects. The PDR Operations Manager will report to the Director of PDR. In this role you will be responsible for ensuring PDR and NSB inventory stays within compliance and regulatory guidelines, manage both onshore and offshore teams, and partner with the PDR Regulatory Audit Manager to create efficiencies in procedures, systems, and develop and implement strategic initiatives that will enhance the PDR department.

Our leadership model is about developing great leaders at all levels and creating opportunities for our people to grow – personally, professionally, and financially. We are looking for leaders that are energized by creative and critical thinking, building and sustaining high-performing teams, getting results the right way, and fostering continuous learning.

Responsibilities

In this role, you will:

• Be responsible for the PDR Operations team over the Commercial, Medi-Cal and Medicare lines of business and the No Surprise Billing Team. Scope of oversight includes planning, cost management, regulatory compliance and strategy, audit preparation and planning, and creating strategic initiatives to drive production
• Demonstrate BSC Leadership Behaviors
• Foster a great place to work by clearly communicating mission, vision, goals, roles, and expectations for team members; celebrating team achievements; building successful working relationships across the organization
• Direct and control the activities of one or more smaller/less complex department(s) or functional area(s) through subordinate supervisors/team leads
• Establish operational objectives for department or functional area and participate with other managers to establish group objectives
• Manage the No Surprise Billing Team and ensure admin fees and cases are completed timely and within compliance standards of the No Surprises Act mandate
• Ensure team processes are efficient and effective to manage case work timely and accurately
• Partner with PDR Regulatory Audit Manager in developing new procedures and guidelines for onshore and offshore PDR teams that are aligned with regulatory requirements and improve quality results through training and oversight
• Establish audit readiness across the team and in partnership with your peers and represent the department during all audit activity
• Present in Operational Committees, trend top drivers of provider disputes, and work with upstream and downstream partners to reduce provider pain points

Qualifications

In this role, you will need:

• A college degree or equivalent experience and minimum 7 years prior relevant experience, including 3 years of management experience gained as a team leader, supervisor or project/program manager
• Understands basic management approaches such as work scheduling, prioritizing, coaching and process execution, work organization, risk management and delegation
• Understands Blue Shield of CA's mission and business plan
• Has functional expertise within the area of responsibility
• Requires advanced knowledge of job area usually obtained through advanced education combined with experience
• Requires previous experience working for a payor in claims or similar business unit
• Requires expertise in at least one or more of the following lines of business – Commercial, Medi-Cal and/or Medicare
• Prior auditing and/or compliance/regulatory experience is preferred
• Possess the acumen to handle complex situations and responsibilities simultaneously with the urgency of immediate demands brought by leadership or other departments

This role requires employees to be in-office based on our hybrid workplace model, balancing purposeful in-person collaboration with flexibility. For most teams, this means coming into the office two days each week. Employees living more than 50 miles from an office location will work with their manager to determine in-office time based on business need.

About Us

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

We believe in fostering a workplace environment that balances purposeful in-person collaboration with flexibility - providing clear expectations while respecting the diverse needs of our workforce. Our workplace model is designed around intentional in-person interaction, collaboration, connection, creativity and flexibility:

• For most teams, this means coming into the office two days per week.
• Employees living more than 50 miles from an office location, out of state employees, and employees in certain member-facing roles should work with their manager to determine in-office time based on business need.
• 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.

The Company reserves the right to require more presence in the office based on business needs, and requirements are subject to change with periodic reviews.

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.

Job Info

• Job Identification 20260650
• Job Category Customer Services and Operations
• Locations Rancho Cordova - Zinfandel A
• Pay Range for California $102900.00 to $154300.00
• Pay Range for Bay Area $115900.00 to $174000.00
• Note 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.