PDR Operations Manager – Disputes & Compliance (Hybrid)

Blue Shield of CA; Los Angeles (CA); Hybrid; USD 120,000 - 180,000; Full time

Job summary

Blue Shield of CA is seeking an experienced PDR Operations Manager to lead provider dispute resolution across Commercial, Medi-Cal and Medicare while aligning NSB processes with regulatory guidelines. The role manages onshore and offshore teams and partners with the PDR Regulatory Audit Manager to improve procedures and systems.

In this hybrid role, you will drive efficiencies, mentorship, and strategic initiatives to strengthen the PDR function and ensure timely, compliant resolutions in a

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, 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

Responsibilities

• Lead the Provider Dispute Resolution (PDR) Operations team and oversee NSB processes across multiple lines of business.
• Ensure PDR and NSB inventory stay within compliance and regulatory guidelines.
• Manage both onshore and offshore teams and collaborate with the PDR Regulatory Audit Manager to create efficiencies in procedures, systems, and develop strategic initiatives.
• Foster leadership development and build high-performing teams to drive results.

Skills

Leadership

People management

Project management

Coaching

Risk management

Prioritization

Decision making

Strategic thinking

Communication

Education

Bachelor's degree or equivalent

Job description

Blue Shield of CA is seeking an experienced PDR Operations Manager to lead provider dispute resolution across Commercial, Medi-Cal and Medicare while aligning NSB processes with regulatory guidelines. The role manages onshore and offshore teams and partners with the PDR Regulatory Audit Manager to improve procedures and systems.

In this hybrid role, you will drive efficiencies, mentorship, and strategic initiatives to strengthen the PDR function and ensure timely, compliant resolutions in a