Blue Shield of California · 1 day ago
Director, Provider Services - Relations
California, United States
Full-time
Hybrid
Senior Level, Lead/Staff
10+ years expBlue Shield of California is a nonprofit healthcare organization committed to creating a sustainable healthcare system. The Director of Provider Services - Relations will lead the Provider Relations team, ensuring effective communication and relationship management between Blue Shield and its contracted provider networks, while also developing strategies to improve provider satisfaction and operational performance.
Financial ServicesHealth InsuranceNon Profit
Responsibilities
Lead the Provider Relations team which serves as the primary liaison between BlueShield and Blue Shield Promise Health Plan and the contracted provider networks upholding transparency, integrity, and reliability in interactions with both internal and external stakeholders
Oversee the management of provider concerns, including but not limited to contract interpretations, claims discrepancies, eligibility and capitation payment issues, credentialing challenges, service area changes, rate load corrections, retroactive member assignments, provider terminations, member moves and third-party disputes
Develop and implement an operations engagement strategy that incorporates statewide Joint Operations Meetings, inclusive of Medi-Cal requirements, and includes interaction with provider leadership. The aim is to support provider satisfaction with Blue Shield, encourage provider wellness, and maintain operational performance in areas such as access to care, member experience, affordability, and sustainability
Manage structured processes for claims disputes and appeals, driving research, root cause analysis, and corrective action plans to prevent recurring issues
Deliver expert insight and guidance for strategic and operational initiatives impacting Provider Relations, driving effective execution of implementation tasks within the team's scope
Provide effective and detailed thought leadership to inform the Blue Shield Provider Engagement Model working with the Performance Enablement Team
Work collaboratively with Provider Partnerships and the Regional Medical Directors, along with other internal provider-facing partners, to execute an overall strategic engagement strategy
Identify and implement process improvement as it pertains to provider operations, contract and regulatory compliance, efficient relationship management and other areas
Establish operational Key Performance Indicators to assess the effectiveness and performance of the Provider Relations team. Define baseline metrics, set measurable targets, and drive achievement through ongoing process improvement
Assess regulatory, government, or organizational mandates to ensure Blue Shield and Blue Shield Promise Health plans comply with all requirements. Work collaboratively with various departments to maintain internal compliance with regulations by leading workgroups and taskforces
Build and lead a high-performing team that meets all operating goals, including cost of health care, clinical quality improvement, regulatory compliance, administrative costs and employee engagement
Foster a culture of innovation and creativity to enable Blue Shield of California to meet changing market conditions and strategy
Promote and model a collaborative and partnership-oriented culture by cultivating strong relationships with internal stakeholders to achieve collective success
Qualification
Required
Requires a college degree or equivalent experience
Requires 10 years prior relevant experience in Provider Relations or healthcare network contracting
Requires 6 years of management experience and must be comfortable operating in a matrixed/collaborative environment
Strong experience and orientation to the quadruple aim coupled with knowledge of markets, sales, operations, product development, network management, clinical operations, finance, regulatory issues and compliance
Able to collaborate and work strategically in a team setting with various professional, technical, and administrative staff, integrating resources in a timely and organized manner
Comprehensive knowledge of managed care risk contracts and the operational requirements involved in managing a provider network
Outstanding verbal and written communication abilities, with demonstrated effectiveness when engaging executive leadership
Demonstrated ability to build enduring, trustworthy relationships and effectively interact across all organizational levels, both internally and externally
Ability to lead and manage significant culture change. Demonstrated experience with change and organization management; possess a performance driven management style
Strong leadership skills, including excellent interpersonal, communications, problem solving and negotiating skills
Ability to think strategically while at the same time drive operational performance
Proven project management experience applying industry methodologies and practices
Technologically savvy and able to utilize information systems and Office software effectively
Proven ability to mentor and coach leaders in their respective teams
Preferred
Master's degree is preferred
Minimum 5 years of direct Medicare and Medi-Cal experience with a Managed Care Organization (MCO) preferred
Previous experience in management of process analysis and improvement
Experience in the development of policies and procedures pertaining to Network Management
Company
Blue Shield of California
Blue Shield of California is a health insurance service provider.
5001-10000 employees
H1B Sponsorship
Blue Shield of California has a track record of offering H1B sponsorships. Please note that this does not
guarantee sponsorship for this specific role. Below presents additional info for your
reference. (Data Powered by US Department of Labor)
Distribution of Different Job Fields Receiving Sponsorship
Represents job field similar to this job
Trends of Total Sponsorships
2023 (1)
2022 (41)
2021 (20)
2020 (31)
Funding
Current Stage
Late StageLeadership Team
Gary Culp
Senior Vice President, Government Markets
Gregory Siebert
Senior Vice President Provider Partnerships & Network Management
Recent News
Fierce Healthcare
2025-12-15
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