Your Role
The Provider Dispute Resolution (PDR) regulatory team completes a variety of audits and researches and responds to regulatory complaints associated with the different regulatory agencies that govern PDR operations, which include, but are not limited to the DMHC, DHCS, CMS, and LA Care. The Operations Specialist, Experienced will report to the Director of PDR. In this role you will work on Medi-Cal regulatory audits and concerns associated with the DMHC, DHCS and LA Care regulatory agencies. You will also be the liaison for the BSC Medi-Cal compliance team and regulatory agencies. As an Operations Specialist, you will work on updating and creating DLPs for the Medi-Cal line of business, provide second level support to QA audit staff and supervisors, and assist in preparing for and participating in regulatory audits. This position will also be considered a Medi-Cal PDR SME for various inter-departmental projects.
Your Work
In this role, you will:
- Act as subject matter expert and reviews operational workflows, identifying problems and develops improvements, modifications, and enhancements
- Maintain databases required for business operations
- Develop and evaluate tools and materials that enhance operating efficiency, accuracy, and technical skill levels of unit staff
- Develop and generate reports for management review; notify appropriate department mangers about issues and problems in operational workflow requiring immediate attention
- Participate as a subject matter expert in the development of written guidelines and documents problems as needed
- Manage critical inter-departmental and PDR specific projects
- Work with the Mandates team to ensure all mandates have flowed through PDR documentation and are updated on a consistent basis
- Create procedure guides and training documents for regulatory complaints associated with all agencies
- Ensure PDR regulatory metrics are being followed properly by coordinators and provide training as necessary
Your Knowledge and Experience
- Requires a bachelor’s degree or equivalent experience
- Requires at least 3 years of prior relevant experience
- Requires prior auditing and/or compliance/regulatory experience
- Requires previous experience working for a payor in claims or similar business unit
- Requires knowledge and proficiency of Microsoft Systems such as Power Point, Excel, and Word
- Requires expertise in the Medi-Cal line of business
- Preferred expertise in the Commercial and/or Medicare line of business
Pay Range
The pay range for this role is: $66700.00 to $93390.00 for California.
Note:
Please note that this range represents the pay range for this and many other positions at Blue Shield that fall into this pay grade. Blue Shield salaries are based on a variety of factors, including the candidate's experience, location (California, Bay area, or outside California), and current employee salaries for similar roles.
ABOUT THE TEAM
Blue Shield of California’s mission is to ensure all Californians have access to high-quality health care at a sustainably affordable price. We are transforming health care in a way that genuinely serves our nonprofit mission by lowering costs, improving quality, and enhancing the member and physician experience.
To fulfill our mission, we must ensure a diverse, equitable, and inclusive environment where all employees can be their authentic selves and fully contribute to meet the needs of the multifaceted communities we serve. Our continued commitment to diversity, equity, and inclusion upholds our values and advances our goal of creating a healthcare system that is worthy of our family and friends while addressing health disparities, promoting social justice, and integrating health equity through our products, business practices, and presence as a corporate citizen.
Blue Shield has received awards and recognition for being a certified Fortune 100 Best Companies to Work, Military Friendly Employer, People Companies that Care, a Leading Disability Employer, and one of California’s top companies in volunteering and giving. Here at Blue Shield, we strive to make a positive change across our industry and communities – join us!
Our Values:
- Honest . We hold ourselves to the highest ethical and integrity standards. We build trust by doing what we say we're going to do and by acknowledging and correcting where we fall short.
- Human . We strive to be our authentic selves, listening and communicating effectively, and showing empathy towards others by walking in their shoes.
- Courageous . We stand up for what we believe in and are committed to the hard work necessary to achieve our ambitious goals.
Our Workplace Model:
Blue Shield of California is dedicated to making work-life balance a reality. Whether you prefer to work in an office or from home, we understand flexibility is more important than ever. That’s why Blue Shield is a hybrid company, offering you the opportunity to decide where you can do your best and most meaningful work.
Two ways of working: Hybrid (our default) and office
- Hybrid – In a business unit approved office a few times per year to 3 days per week, on average
- Office – In a business unit approved office 4+ days a week, on average. If the role you’re applying for is deemed an “Essential Role,” the company has determined that the role can only be performed in a Blue Shield office or in the field and would require your to meet the office worker classification.
Physical Requirements:
Office Environment - roles involving part to full time schedule in Office Environment. Due to the current public health emergency in California, Blue Shield employees are almost all working remotely. Based in our physical offices and work from home office/deskwork - Activity level: Sedentary, frequency most of work day.
Equal Employment Opportunity:
External hires must pass a background check/drug screen. Qualified applicants with arrest records and/or conviction records will be considered for employment in a manner consistent with Federal, State and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regards to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or disability status and any other classification protected by Federal, State and local laws.
