Derek Halley
Folsom,CA
Summary
Versatile Senior Manager with over 18 years at Blue Shield of California, specializing in Operations Management and Outsourcing. Skilled at planning, implementing and overseeing key improvements to drive business growth and efficiency. History of cultivating an open culture with free exchange of information. Pursuing new professional challenges with a growth-oriented company, underscored by my Scrum Master and PMP certifications..
Overview
19
19
years of professional experience
Work History
Senior Manager, Appeals & Grievances
Blue Shield of California
07.2022 - 08.2024
- Managed Commercial Clinical, Regulatory and Outsourced Operations Appeals & Grievances teams
- Managed large-scale projects to reduce administrative expenses aligned with annual budget targets through business process outsourcing and process improvements
- Conducted performance evaluations, compensations and hiring to maintain appropriate staffing requirements.
- Implemented and developed operational standards, policies and procedures.
- Provided strong leadership to enhance team productivity and morale resulting in 100% Employee Engagement scores
- Assisted in organizing and overseeing assignments to drive operational excellence.
- Maintained positive customer relations by addressing problems head-on and implementing successful corrective actions.
- Established performance goals for employees and provided feedback on methods for reaching those milestones.
- Facilitated Professional Development sessions for Organizational Leaders and future leaders
- Managed senior-level personnel working in sales, legal and clinical capacities.
- Streamlined and monitored quality programs to alleviate overdue compliance activities.
Senior Manager, Medicare Operations
Blue Shield of California
12.2018 - 07.2022
- Managed Medicare and Medi-Cal Operations teams including Enrollment, Billing and Claims
- Managed large-scale projects such as development of new Claims Compliance function and system enhancement for Medicare Enrollment processes resulting in 40% reduction in manual work
- Conducted performance evaluations, compensations and hiring to maintain appropriate staffing requirements.
- Implemented and developed operational standards, policies and procedures.
- Provided strong leadership to enhance team productivity and morale resulting in 100% Employee Engagement scores
- Managed Medi-Cal Merger for process integration with Enrollment and Billing teams to maintain compliance while supporting employee engagement
Senior Manager, Customer Experience Project Team
Blue Shield of California
01.2017 - 12.2018
- Managed Operational Support team of 15 Analysts in additional to Quality Compliance function
- Managed team that supported large-scale projects including new systems, tools, mandates and process improvement initiatives
- Led Lean Six Sigma events to streamline team structure and enable efficiencies to support all enterprise projects without additional staffing
- Quality program oversight for Medicare Operations and Appeals & Grievances functions
- Provided strong leadership to enhance team productivity and morale resulting in 100% Employee Engagement scores
Senior Manager, Customer Experience Quality
Blue Shield of California
07.2014 - 01.2017
- Managed Quality program for Customer Service, Medicare Operations and Appeals & Grievances teams
- Managed large-scale project to develop new quality program in support of business challenges across all functions
- Quality program implementation for Customer Service included three lines of business across 10 call centers globally
- Established robust oversight, business partner collaboration and controls to ensure consistency and value of output from quality team
- Customer Satisfaction increased 16 points after first year of program implementation
Vendor Management, Consultant
Blue Shield of California
07.2012 - 07.2014
- Managed four call centers globally with ~1000 employees supporting Member and Provider phone inquiries
- Managed large-scale project opening two call centers with~400 employees to support forecasted volumes associated with Health Care Reform Regulation
- Established business oversight controls to ensure all service level requirements were being met consistently and to address new challenges real time through daily operational oversight calls
- Conducted contractual audits annually to ensure compliance
Supervisor, Appeals & Grievances
Blue Shield of California
02.2010 - 07.2012
- Supervised Commercial Regulatory and Self Funded Non-Clinical Appeals team
- Applied strong leadership talents and problem-solving skills to maintain team efficiency and organize workflows.
- Optimized customer experience by delivering superior services and effectively troubleshooting issues.
- Provided reporting for forecast analysis and ad-hoc reporting in support of decision-making.
- Worked directly with Law Department on complex legal issues
- Implemented critical processes to maintain compliance with regulatory demands included the development of specialty team that provided behavioral health case management services
Operations Specialist, Vendor Management
Blue Shield of California
08.2007 - 02.2010
- Provided Subject Matter Expertise and Oversight of Outsourced call centers across two sites with ~400 employees
- Project Manager for multiple initiatives to outsource work to existing sites offshore resulting in meeting organization budget cost savings
- Conducted regular reviews of operations and identified areas for improvement.
- Helped meet changing demands by recommending improvements to business systems or and making process update to optimize performance.
- Established employee incentive plans for vendor staff to drive quality and performance improvements
- Conducted on site product training for staff
Special Accounts/Priority Customer Service
Blue Shield of California
01.2006 - 08.2007
- Followed-through on all critical inter-departmental escalations to increase customer retention rates.
- Enhanced productivity levels by anticipating needs and delivering outstanding support.
- Promptly responded to inquiries and requests from prospective customers.
- Assisted high profile groups on escalated issues
- Interim Supervisor for Customer Service Team for 6 months
Education
Bachelor of Arts - Organizational Behavior And Leadership
University of San Francisco
San Francisco, CA06.2025
Skills
- 18 Years of Healthcare experience
- Extensive experience in Operational and Vendor Management
- Cross Functional Partnership Development
- Project Management
- Strategic Planning
- Budget Oversight
- Leadership and Employee Engagement
- Scrum Master and PMP Certified
Timeline
Senior Manager, Appeals & Grievances
Blue Shield of California
07.2022 - 08.2024
Senior Manager, Medicare Operations
Blue Shield of California
12.2018 - 07.2022
Senior Manager, Customer Experience Project Team
Blue Shield of California
01.2017 - 12.2018
Senior Manager, Customer Experience Quality
Blue Shield of California
07.2014 - 01.2017
Vendor Management, Consultant
Blue Shield of California
07.2012 - 07.2014
Supervisor, Appeals & Grievances
Blue Shield of California
02.2010 - 07.2012
Operations Specialist, Vendor Management
Blue Shield of California
08.2007 - 02.2010
Special Accounts/Priority Customer Service
Blue Shield of California
01.2006 - 08.2007
Bachelor of Arts - Organizational Behavior And Leadership
University of San Francisco
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