Manager, Claims

About the role

Implements an end-to-end service model across provider segments and ensures delivery against business targets. Sets performance and process targets within customer segment(s) to enable high levels of claims processing, claims financial processing, and customer service. Manages claims submission, refunds, and recovery from all lines of business for assigned customer segment(s). Collaborates with claims leadership to understand customer segment(s) and contractual obligations. Responsible for claims accounting and financial reporting.

Responsibilities

• Streamline shared processing to reduce management by exception
• Set operational processes to address market trends, BCBSNC capabilities, and customer demand
• Manage accounting and financial reporting functions in support of the Finance Division, including overseeing the gathering, preparation, analysis, and reconciliation of financial data to ensure compliance with accepted accounting principles and standards
• Research and resolve banking issues
• Participate in projects to improve and/or facilitate claims processing, recovery, and accounting functions
• Manage financial recovery activities including refunds and collections
• Manage team leads and staff by efficiently driving work volume to maintain high levels of utilization and engagement
• Resolve complex claims appeals by coordinating with different stakeholders for high-value claims
• Collaborate with Audit and Payment Integrity to sustain a predetermined level of accuracy and quality
• Design and develop tools and techniques for improvements; identify needed process and procedural changes to improve customer satisfaction
• Negotiate Claims ASO performance guarantees, reviews, approvals, and client RFPs in collaboration with the Sales organization
• Serve as ASO Claims Subject Matter Expert and single point of contact for performance monitoring and troubleshooting
• Represent Claims Operations to ASO executives by providing data, reports, analytics, and expertise routinely and on demand
• Support ASO Channel lead as the Claims ASO Subject Matter Expert and act as single point of contact both internally and to the ASO for all Claims, Claims Recovery, and Claims Accounting-related escalations

Requirements

• Bachelor's degree or advanced degree (where required)
• 8+ years of experience in a related field
• In lieu of degree, 10+ years of experience in a related field

Qualifications

• Demonstrated claims operations experience in a regulated claims environment (Medicare, government programs, or similar)
• Experience leading claims teams and performance management
• Proven understanding of claims systems and processing workflows
• Data analytics and reporting experience
• Experience with Facets or similar claims platforms (strongly preferred)

Benefits

• Medical, dental, and vision coverage along with numerous health and wellness programs
• Parental leave and support plus adoption and surrogacy assistance
• Career development programs and tuition reimbursement for continued education
• 401k match including an annual company contribution
• Paid Time Off (PTO)
• Annual Incentive Bonus based on annual corporate goal achievement and individual performance

Pay

Starting salaries are typically planned near the middle of the range listed. Compensation decisions are driven by factors including experience, training, specialized skill sets, licensure, certifications, and business needs.

Salary range: $107,901.00 - $172,642.00

Skills

• Accounts Receivable (AR)
• Claims Analysis
• Claims Management
• Claims Processing
• Claims Resolution
• Claims Submission
• Documentation
• Financial Processing
• Health Insurance
• Insurance Claim Handling
• Insurance Claims Processing
• Insurance Industry
• Medicare Advantage
• People Management
• Recruiting