Manager, Operations

About the 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.

Responsibilities

• 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.
• 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.
• 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.
• Present in Operational Committees, trend top drivers of provider disputes, and work with upstream and downstream partners to reduce provider pain points.

Qualifications

• 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.
• 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.