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Senior Director, Consumer Experience and Operational Compliance Job
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| Employer Name: |
SpiderID: 14066066 |
| Location: Woodland Hills, California |
Date Posted: 9/17/2025 |
| Wage: Negotiable |
Category: Insurance |
| Job Code: 170021G-2191 |
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Job Description:
 Looking for a chance to do meaningful work that touches millions? Come join the hardest working, nonprofit health plan in California and help us shape the future of health care. Blue Shield of California is focused on transforming health care by making it more accessible, affordable and customer-centric. Being a mission-driven organization means we do much more than serve our 3.5 million members: we were the first health plan in the nation to limit our annual net income to 2 percent of revenue and return the difference to our customers and the community, and since 2005 we have contributed more than million to the Blue Shield of California Foundation to improve community health and end domestic violence. We also believe that a healthier California begins with our employees, so we provide them with resources to develop and maintain a healthy lifestyle through our award-winning wellness program, Wellvolution.
We're hiring smart thinkers and doers who want to work for a leader and innovator in the challenging, ever-changing healthcare space. Come and help us make health care better for everyone.
Description:
Opportunity
This role provides effective and inspiring leadership, as well as stewardship, of the Blue Shield Senior Markets by overseeing the end-to-end operational aspects of BSC programs and services for a seniors including all products sold in this market (Medicare Advantage, Medicare Supplemental Coverage, Group Retiree Products, Medicare Prescription Drug Plan, Duals and Special Needs Plans). This segment is a high priority segment for Blue Shield of California with aggressive expansion and growth planned in the near and long term. The AVP- Consumer Experience and Operational Compliance - Senior Markets has accountability for the short-term and long-range operational and business compliance plans, establishing policy and procedures as needed, and providing direction to the various operational teams in support of the LOB.
This position will be based in our Woodland Hills, CA office and lead a direct team with a matrixed/shared partners oversight of upwards of 400 professionals.
Essential Duties and Responsibilities
• Ensure that the overall consumer experience in Senior Markets is consistently delivered and that we maintain thoughtful and efficient compliance with all laws, regulations and contractual requirements related to Senior Markets
• Implement and lead a continuous quality improvement process throughout the program and service areas, focusing on CMS-compliant systems/process improvement
• Develop and maintain and end-to-end consumer touch point map and establish key indicators that will be routinely monitored to ensure delivery of our planned consumer experience and compliance with all service standards
• Lead a high performing team to the next level by further developing and implementing recruitment, training, and retention strategies
• Ensure that all program activities operate consistently and ethically within the mission and values of BSC, CMS, HHS and other regulatory bodies
• Prepare and submit an annual operational budget to BSC leadership for review and approval; manage effectively within this budget, and report accurately on progress made and challenges encountered
• Ensure the continued financial viability of the Senior Markets suite of products through sound fiscal management. Provide programmatic leadership and input for all strategic planning processes with the leadership team. Assist the Vice President of Senior Markets in the annual development of product, service and rate strategies which ensure continued growth of our Senior Markets
• Provide oversight for the business compliance team which includes:
◦ Meeting all federal and state guidelines to ensure the plan's adherence to CMS policies and procedures
◦ Hire and develop a dedicated team with a high level performance and knowledge of Medicare statutes
◦ Ensure every client and CMS, and regulatory complaint receives prompt and accurate resolution
• Maintains a high level of exposure and awareness on changes with the regulatory and political environment that characterizes a government-sponsored program such as Medicare and politically active group such as seniors. Maintains "domain expert" status in all matters related to Senior Markets.
• Oversees, monitors and collaborates with functional areas across the enterprise who impact the success of the LOB -- Customer Service, Enrollment, Appeals & Grievances, Claims, Network Management, Star Program, Revenue Management, Medical Management, Corporate & Medicare Compliance, Internal Audit, Finance, Actuary, Marketing, Sales, Product, Pharmacy, Legal and IT.
• Responsible for understanding and driving the financial performance supported by the Finance Team (planning, reporting, performance management, contract support, capitation payments, analysis, coding and budgeting). Particular focus on monitoring and overseeing Operational execution against administrative costs.
•Drives the enterprise wide definition of senior "consumer experience" and effectively influences the organization in the delivery of this experience
• Partners with other BSC cross functional teams to ensure services provided to our members is effective and meeting the changing needs of our customers.
• Collaborates with the Large Group Business Unit (LGBU) on meeting their customer needs for group retirees.
• Collaborates with other BSC leaders and cross-function business units to improve our operational effectiveness.
• Provides effective thought leadership to the Leadership Team, other cross-functional leaders throughout BSC and the BSC Executive team on Senior and Medicare related issues.
• Responsible for the integration planning and oversight of acquired membership and/or organizations.
•Responsible for educating and keeping BSC current on changes in the marketplace as well as state and federal regulatory changes.
• Provides effective leadership in attracting and retaining top talent to drive the business results for the business segment.
• Works in partnership with customers, vendors, and other key stakeholders to deliver the service and products required.
•Develop Medicare network strategy and collaborate with HCQA leaders on implementation.
•Create and implement cost of healthcare savings opportunities for the Medicare population.
Conceptual Competencies
• Conceptual/Strategic thinking: Ability to understand a situation or problem by putting the pieces together, seeing the larger picture and its internal or competitive implications. It includes identifying patterns or connections between situations that are not obviously related; identifying key or underlying issues in complex situations.
• Analytical thinking: Ability to organize the parts of a problem or situation in a systematic way, making systematic comparisons of different features or aspects; setting priorities on a rational basis; identifying time sequences, causal relationships or if/then relationships.
• Technical: General management experience that includes substantial responsibility for operations and compliance in a health care environment specifically in senior markets required. Broad knowledge of the healthcare industry including regulatory/operational trends, markets, competitors, financing, regulation, and risk management.
Managerial Competencies
• Operational Execution: Ability to lead direct and indirect operational teams to achieve business performance and deliver CMS requirements in an effective and efficient manner.
• Developing others: Ability which includes the intent and capability to teach or foster the learning or development of one or several other people including the ability to do the appropriate level of need analysis.
• Teamwork & cooperation: Genuine intention to work collaboratively/cooperatively with others, to be part of a team, to work together as opposed to working separately or competitively.
• Team leadership: Ability to use complex strategies to promote team morale and productivity (hiring/firing decisions, team assignments, cross-training);treating all members fairly regardless of personal feelings; making sure that the practical needs of a group are met including obtaining resources and removing barriers to success; and achieving alignment regarding mission, goals, agenda, climate, tone, and policies.
Leadership/Interpersonal Competencies
• Achievement orientation: Willingness and ability to compete against a standard of excellence including one's own, an objective measure, the performance of others (competitors) or the yet unknown, which represents innovation.
• Strategic future orientation: A bias for action that propels the organization forward and represents doing more than is required or expected by the job, customers, direct reports, peers or other stakeholders. It involves doing this when it has not been requested simply because it will create new opportunities.
• Strategic influencing: Ability to use oneself as a tool to persuade and build commitment to the vision, mission and goals of the company and to do this without using hierarchical power to get others to adopt a course of action. Strategic influencing is used at all levels in the company and with customers, regulators,vendors, and other stakeholders.
• Information seeking: A desire to know more about things, people, or issues that drives a quest and curiosity about the business, its competitors, processes, etc. that goes well beyond what is required. Information seeking involves "digging" or pressing for exact information or resolution of discrepancies by asking a series of questions; scanning for potential opportunities or for miscellaneous information that may be of future use; or getting out personally to see the situation in order to understand it better.
Personal Effectiveness Competencies
• Relationship building: Ability to build and maintain friendly, warm relationships or networks of contacts with people who are, or might someday be, useful (in a constructive sense of the word) in achieving work-related goals. The behaviors include: consciously "working at:" building rapport, extending oneself to build rapport; establishing rapport easily; sharing one's self to create a common ground or mutuality; or "networking" with others.
• Organization awareness: Ability to understand the power relationships in an organization - both yours and the customers' including the ability to identify who are the real decision makers and the individuals who can influence them; and to predict how new events or situations will affect individuals and groups within the organization, or the organization's position vis-à-vis national or international markets, organizations, or politics.
Qualifications:
Candidate Profile and Requirements
The AVP- Consumer Experience and Operational Compliance will have proven experience in operational and compliance effectiveness. This individual will possess a strong compliance and operational orientation coupled with intimate knowledge of regulatory requirements, best practice / operational excellence, finance, and process improvement. He/She must also be a proven manager/leader comfortable operating in a matrixed/collaborative environment. In short, the successful candidate is an outstanding general manager successor. Ideally, the candidate will possess:
• A minimum of seven years of management experience with an HMO/managed care insurer.
• A minimum of five years experience in the Medicare managed care environment (MA, PDP,SNP).
• Prior Medicare operations and/or compliance experience.
The successful candidate will be a team player, strategic, growth-oriented and a subject matter expert.
Qualifications
The successful candidate will have a bachelor's degree; a MBA or advanced degree is preferred.
Job Criteria:
Start Date:
Position Type: Full-Time Permanent
Years of Experience Required:
Education Required:
Overnight Travel:
Vacation Time:
Contact Information:
| Contact Name: Blue Shield of California |
Company Type: |
| Company: Blue Shield of California |
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