Job Description

Your Role

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.

Responsibilities

Your Work
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

Your Knowledge and Experience

• Requires 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

Hybrid

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.

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.