PDR Operations Lead: Provider Disputes & Compliance

Blue Shield of California; California (MO); Hybrid; USD 103,000 - 154,000; Full time

Job summary

Blue Shield of California seeks an experienced PDR Operations Manager to lead the Provider Dispute Resolution team across Commercial, Medi-Cal and Medicare, including the No Surprise Billing initiative. You will report to the Director of PDR and drive regulatory compliance, efficiency, and strategic improvements for both onshore and offshore teams.

The role emphasizes leadership development, cross-functional collaboration, and delivering results while maintaining compliance.

Qualifications

• Requires a college degree or equivalent experience and minimum 7 years prior relevant experience, including 3 years of management experience.
• Understands basic management approaches such as work scheduling, prioritizing, coaching and process execution.
• Experience working for a payor in claims or similar business unit.
• Expertise in at least one of Commercial, Medi-Cal and/or Medicare lines of business.
• Prior auditing and/or compliance/regulatory experience preferred.

Responsibilities

• Oversee the PDR Operations team across Commercial, Medi-Cal and Medicare lines, including No Surprise Billing Team, with focus on planning, cost management, regulatory compliance and strategy.
• Demonstrate Blue Shield of CA leadership behaviors and foster a high-performing team.
• Communicate mission, vision, goals, roles, and expectations across the organization; celebrate team achievements.
• Direct and control activities of departments through supervisors or team leads; set objectives and collaborate on group goals.
• Manage No Surprises Billing Team and ensure admin fees and cases meet regulatory standards of the No Surprises Act.
• Ensure efficient and accurate handling of case work; drive timely delivery.
• Partner with PDR Regulatory Audit Manager to develop procedures for onshore/offshore teams aligned with regulatory requirements and quality goals.
• Establish audit readiness and represent the department during audits.
• Present at Operational Committees and collaborate with partners to reduce provider pain points.

Skills

Management experience

Regulatory compliance

Audit readiness

Strategic planning

Team leadership

Communication

Education

Bachelor's degree or equivalent experience

Job description

Blue Shield of California seeks an experienced PDR Operations Manager to lead the Provider Dispute Resolution team across Commercial, Medi-Cal and Medicare, including the No Surprise Billing initiative. You will report to the Director of PDR and drive regulatory compliance, efficiency, and strategic improvements for both onshore and offshore teams.

The role emphasizes leadership development, cross-functional collaboration, and delivering results while maintaining compliance.