Manager, Operations

Blue Shield of CA; Springfield Meadows (CA); On-site; USD 140,000 - 180,000; Full time

Job summary

Blue Shield of California is seeking an experienced PDR Operations Manager to oversee provider disputes across Commercial, Medi-Cal and Medicare, coordinating onshore and offshore teams and ensuring tasks stay compliant with regulatory requirements.

You will partner with the PDR Regulatory Audit Manager to drive process improvements, lead with a growth mindset, and implement strategic initiatives that strengthen the PDR function and advance organizational goals.

Qualifications

• Requires college degree or equivalent experience and minimum 7 years prior relevant experience, including 3 years management experience
• Understands work scheduling, prioritizing, coaching and process execution
• Experience in a payor claims or similar business unit preferred

Responsibilities

• Oversee PDR/NSB operations across Commercial, Medi-Cal and Medicare lines
• Manage onshore and offshore teams and ensure inventory stays within regulatory guidelines
• Partner with the PDR Regulatory Audit Manager to improve procedures, systems and implement strategic initiatives

Skills

Leadership

Project management

Regulatory/compliance

Risk management

Education

Bachelor's degree

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.

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 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.