Blue Shield of California

Job Description

Your Role

Reporting to the VP, Network Operations, the Director, Provider Services - Relations, Blue Shield of California and Promise Health Plan (BSCPHP), is responsible for creating and maintaining high integrity relationships with risk-baring medical providers, hospitals and health systems in their assigned region to enable BSCPHP to become the health plan of choice. The outcome of being the ideal partner for our providers will be to materially improve cost, quality, maintain compliance, service and together grow membership in service to our communities across BSCPHP business. The Director will lead in a highly matrixed environment across multiple internal business teams to provide strategic alignment, business planning, and effective execution of the business plans for all providers in their region for BSCPHP business as well as partner with all lines of business as they impact our Provider Network.

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.

Responsibilities

Your Work

In this role, you will:

• 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

Qualifications

Your Knowledge and Experience

• Requires a college degree or equivalent experience. Master’s degree is preferred
• 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
• 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
• 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

ABOUT US

About Blue Shield of California

As of January 2025, Blue Shield of California became a subsidiary of Ascendiun. Ascendiun is a nonprofit corporate entity that is the parent to a family of organizations including Blue Shield of California and its subsidiary, Blue Shield of California Promise Health Plan; Altais, a clinical services company; and Stellarus, a company designed to scale healthcare solutions. Together, these organizations are referred to as the Ascendiun Family of Companies.

At Blue Shield of California, our mission is to create a healthcare system worthy of our family and friends and sustainably affordable. 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 achieve our mission, we foster an environment where all employees can thrive and contribute fully to address the needs of the various communities we serve. We are committed to creating and maintaining a supportive workplace that upholds our values and advances our goals.

Blue Shield is a U.S. News Best Company to work for, a Deloitte U.S. Best Managed Company and a Top 100 Inspiring Workplace. We were recognized by Fair360 as a Top Regional Company, and one of the 50 most community-minded companies in the United States by Points of Light. 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 listen and communicate effectively, showing empathy by understanding others' perspectives.
• 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:

At Blue Shield of California and the Ascendiun Family of Companies, we believe in fostering a workplace environment that balances purposeful in-person collaboration with flexibility. As we continue to evolve our workplace model, our focus remains on creating spaces where our people can connect with purpose – whether working in the office or through a hybrid approach – by providing clear expectations while respecting the diverse needs of our workforce.

Two Ways of Working:

• Hybrid (Default): Work from a business unit-approved office at least two (2) times per month (for roles below Director-level) or once per week (for Director-level roles and above). Exceptions:

o Member-facing and approved out-of-state roles remain remote.

o Employees living more than 50 miles from their assigned offices are expected to work with their managers on a plan for periodic office visits.

o For employees with medical conditions that may impact their ability to work in-office, we are committed to engaging in an interactive process and providing reasonable accommodations to ensure their work environment is conducive to their success and well-being.

• On-Site: Work from a business unit-approved office an average of four (4) or more days a week.

Physical Requirements:

Office Environment - roles involving part to full time schedule in Office Environment. Based in our physical offices and work from home office/deskwork - Activity level: Sedentary, frequency most of work day.

Please click here for further physical requirement detail.

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.

• Job Identification 20252463
• Job Category Provider Network
• Posting Date 12/19/2025, 08:15 PM
• Job Schedule Full time
• Locations Long Beach, CA, United States CA, United States El Dorado Hills, CA, United States Lodi, CA, United States Oakland, CA, United States Rancho Cordova, CA, United States Redding, CA, United States San Diego, CA, United States Woodland Hills, CA, United States
• Pay Range for California $158620.00 to $238040.00
• Pay Range for Bay Area $178808.00 to $268336.00
• 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 experience, location (California, Bay Area, or outside California), and current employee salaries for similar roles.
• Role can be filled by a candidate requiring sponsorship No

Pay Range for California $158620.00 to $238040.00 Pay Range for Bay Area $178808.00 to $268336.00 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 experience, location (California, Bay Area, or outside California), and current employee salaries for similar roles.