Senior Manager of Operations, Provider Dispute Resolution

o About Blue Shield of California: For more than 80 years, Blue Shield has been dedicated to transforming health care by making it more accessible, cost-effective, and customer-centric. We are a not-for-profit, independent member of the Blue Cross Blue Shield Association with 7,500 employees, more than $21 billion in annual revenue and 4.5 million members. The company has contributed more than $500 million to the Blue Shield of California Foundation since 2002 to have a positive impact on California communities. Blue Shield is headquartered in Oakland, California with 21 additional locations including Sacramento, Los Angeles, and San Diego.
o Our Benefits: At Blue Shield you can expect a comprehensive benefits program that offers choice and flexibility for our diverse workforce. These programs and resources include: Medical, Dental, and Vision plan benefits, 401(k) with employer match, paid time off (PTO), earned sabbatical time, paid nonprofit volunteer time, flexible work program, free online education, tuition reimbursement, a wellness reimbursement program, 12 weeks paid parental leave, and more.

Description

Blue Shield of California's mission is to ensure all Californians have access to high-quality health care at a sustainably affordable price. We are transforming health care in a way that truly serves our nonprofit mission by lowering costs, improving quality, and enhancing the member and physician experience.

To fulfill our mission, we must ensure a diverse, equitable, and inclusive environment where all employees can be their authentic selves and fully contribute to meet the needs of the multifaceted communities we serve. Our comprehensive approach to diversity, equity, and inclusion combines a focus on our people, processes, and systems with a deep commitment to promoting social justice and health equity through our products, business practices, and presence as a corporate citizen.

Blue Shield has received awards and recognition for being a certified Great Place to Work, best place to work for LGBTQ equality, leading disability employer, one of the best companies for women to advance, Bay Area's top companies in volunteering & giving, and one of the world's most ethical companies. Here at Blue Shield of California, we are striving to make a positive change across our industry and the communities we live in - join us!

Your Role

The Provider Dispute Resolution team supports the Medicare and Medi-Cal lines of business responding to Provider requests to dispute their previously processes Blue Shield claims while identifying gaps within the Blue Shield of California processes driving disputes . The Senior Manager of Operations for Provider Dispute Resolution will report to the Senior Director of Operations - Broker, Employer and Provider Services . In this role you will be responsible for ensuring the success of our operational performance. Your daily effort will include driving our operational performance to ensure achievement of key performance indicators, accuracy of case adjudication, and development of staff. Additionally, you will lead cross functional collaboration across key stakeholder departments showcasing insights from the Provider Dispute Resolution intake and triage workflows identifying the root cause issues driving dispute volumes and partnering to develop and execute on remediation plans improving upstream accuracy and reducing provider abrasion. 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.

Your Work

In this role, you will:

  • Responsible for the strategic and tactical planning for the provider dispute resolution team for Medi-Cal and Medicare. Manages service, regulatory, and financial performance of the Provider Dispute Resolution function making sure that BSC is always compliant. Own the budget management, resource management, process improvements, and technology changes for the Provider Dispute Resolutions department
  • Establishes operational objectives ensuring customer driven KPIs and goals are in place, which are reflective of and measure our strategic, competitive, and regulatory position with ongoing measurement, reporting, and root cause analysis leveraging lean methodologies to continually identify areas of improvement. Develops enhanced tracking, analytics and reporting of current PDR reasons and resolutions to clearly articulate provider pain points to partners in the organization which results in influencing change and service improvements
  • Defines and implements operational structure & processes to facilitate business performance driving continual gap evaluation of operational process & technology for efficiency transformation
  • Provides direction and management for Regulatory (DMHC, CDI), Accreditation (NCQA, URAC) and employer group audits; includes documentation of evidence supporting compliance, interpretation of regulatory requirements into operational procedures for adjustment, the onsite file review and the interview processes and the written response processes. Implements changes based on audit findings along with internal controls to maintain compliance
  • Partner with key upstream business units (claims, contracting, partner relations) working cross-functionally to align department policies, procedures, and results through a reduction of upstream errors
  • Fosters a great place to work by clearly communicating mission, vision, goals, roles, and expectations for team members; recognizing top talent and team achievements; building successful working relationships across the organization; ensuring a safe and healthy work environment; delivering the tools, time, and talent needed to succeed




Qualifications

Your Knowledge and Experience

  • Requires a bachelor's degree or equivalent experience
  • Requires at least 10 years of prior relevant experience, including 4 years of management experience
  • Requires practical knowledge in leading and managing the execution of processes, projects, and tactics within an area
  • Has advanced knowledge and skills including technical or functional expertise, business acumen, financial analysis skills, risk management, delegation skills, critical thinking, and decision-making skills
  • In-depth knowledge of Blue Shield of California's mission, vision and strategy and healthcare industry environment


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 be our authentic selves, listening and communicating effectively, and showing empathy towards others by walking in their shoes
  • Courageous. We stand up for what we believe in and are committed to the hard work necessary to achieve our ambitious goals




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.


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.
COVID-19 update: From the earliest days of the pandemic, Blue Shield of California has been unyielding in our commitment to putting the health and safety of our people, our members and our communities first. As a federal contractor and a health care company, Blue Shield requires all employees to be fully vaccinated prior to start date as a condition of employment and provide proof of vaccination status. Blue Shield will consider requests for medical or religious accommodation to this vaccination requirement prior to your start date
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