JOB DESCRIPTION
Your Role

The Medi-Cal Operations team plays a critical role in ensuring that the enterprise and business unit goals are met. The Senior Director, Medi-Cal Operations will report to the Vice President, Medi-Cal Performance Optimization. In this role you will oversee the California Advancing and Innovating Medi-Cal (CalAIM), Business Optimization including the Promise Project Management/Agile Office, Medi-Cal Program Support, Business Process Solutions, Medi-Cal Training, and Medi-Cal Policy and Procedure oversight and governance, Payment Integrity and support teams. The work helps deliver and meet DHCS regulatory requirements and execute on our mission. Our leadership model is about developing great leaders at all levels and creating opportunities for our people to grow – personally, professionally, and financially. We are looking for leaders that are energized by creative and critical thinking, building and sustaining high-performing teams, getting results the right way, and fostering continuous learning.

Your Work

In this role, you will:

• Own matrix relationships influencing health plan operations and strategic care management including but not limited to care management, clinical access, customer care operations, behavioral health, enrollment, encounters, claims, transportation, service delivery, appeals and grievances, provider dispute resolution, and utilization management
• Develop business and operations improvement strategies for Medi-Cal Health Plan and Clinical Operations; Oversee service, regulatory and financial performance of the Medi-Cal Health Plan and Clinical Operations teams
• Define and support the implementation of organizational and operational structures, systems and processes to facilitate business performance including operations improvement and regulatory requirements; Ensure business optimization of resources and processes
• Provide executive oversight and leadership to Managers responsible for creating and driving implementation of operating plans, which are required to support immediate and long-term regulatory requirements and strategic and operational business strategies
• Ensure customer driven Key Performance Indicators (KPI’s) and goals are in place, which are reflective of and measure our strategic, competitive and regulatory position with on-going measurement, reporting and root cause analysis.
• Lead end-to-end process improvements throughout the organization designed to create efficiencies and allow us to scale for growth and/or meet regulatory requirements, such as increasing automation and adoption of self-service; Oversees program implementation of annual business unit system development priorities impacting Medi-Cal business operations or regulatory improvements under the BSC Strategic Portfolio.
• Cost of Healthcare and Payment Integrity: Oversees the execution of an integrated payment integrity portfolio that increases financial performance of the Promise business.; Oversees strategies for initiatives targeting scalable and sustainable Medi-Cal growth
• Regulatory Audits: Provides direction and management for Regulatory (DMHC, DHCS, CMS.), including documentation of evidence supporting compliance, the onsite file review and the interview processes and the written response processes; Maintain Regulatory Compliance with DMHC, DHCS and CMS requirements along with managing risk for audits both internal and external
• Provide thought leadership to the Medi-Cal organization and other cross-functional leaders throughout BSC and Promise
• Provide effective leadership in attracting and retaining top talent to drive the business results for this business segment

QUALIFICATIONS
Your Knowledge and Experience

• Requires a bachelor’s degree or equivalent experience
• Requires a master’s degree or equivalent experience
• Requires at least 10 years prior relevant experience, including 6 years of management experience
• In-depth experience with regulatory agencies (e.g. DMHC, DHCS, and CMS etc.) required
• Experience leading healthcare operations and/or process improvement teams required
• Ability to influence, engage and collaborate with senior/executive leadership teams in a cross-functional and highly matrix organization is required
• Strategic thinker with an attention for detail is required

Preferred Knowledge and Experience

• Management consulting experience

Pay Range:
The pay range for this role is: $ 193600.00 to $ 290400.00 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 truly 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 comprehensive approach to diversity, equity, and inclusion combines a focus on our people, processes, and systems with a deep commitment to promoting social justice and health equity through our products, business practices, and presence as a corporate citizen.

Blue Shield has received awards and recognition for being a certified Great Place to Work, best place to work for LGBTQ equality, leading disability employer, one of the best companies for women to advance, Bay Area’s top companies in volunteering & giving, and one of the world’s most ethical companies. Here at Blue Shield of California, we are striving to make a positive change across our industry and the communities we live in – 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.

From the earliest days of the pandemic, Blue Shield of California has been unyielding in our commitment to putting the health and safety of our people, our members and our communities first. As a health care company, Blue Shield requires all employees to be up to date with COVID-19 vaccination prior to start date as a condition of employment. Blue Shield will consider requests for medical or religious accommodation to this vaccination requirement prior to your start date.

The definition of "up to date with your COVID-19 vaccine" is when you have received all doses in the primary series and one booster when eligible. If you are unable to be up to date with your COVID-19 vaccine by your start date, your start date will need to be postponed and you will have 30 days to remedy. If you cannot fulfill the requirement nor obtain an accommodation within 30 days, your offer will be rescinded.