Manager, Claims

Job Description

We’re seeking a Manager of Claims to lead the Commercial Claims Operations Team! The Manager, Claims implements end to end service model across provider segments and ensures delivery against business targets. The role sets performance and process targets within customer segment(s) to enable high level 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. This role is also responsible for claims accounting and financial reporting.

• Streamline shared processing to reduce management by exception
• Set operational process 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.
• 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 keep high level of utilization and engagement in the group
• Resolve complex claims appeal by coordinating with different stakeholders for certain high value claims
• Collaborate with Audit and Payment Integrity to sustain a pre‑determined level of accuracy and quality
• Design and develop tools and techniques for improvements. Identifies needed process and procedural changes which will result in improved customer satisfaction.
• Negotiate Claims ASO performance guarantees, reviews, approvals, and client RFPS in collaboration with Sales organization
• Serve as Commercial Claims Subject Matter Expert and single point of contact for performance monitoring and troubleshooting.
• Represent Claims Operations on monthly Performance Guarantee Oversight and bi‑weekly Sales & Service Operations leadership calls providing status updates, data, reports, analytics, and expertise routinely and on demand.
• Ability to engage as requested by Compliance with regulatory entities, serve as an internal point of contact to prepare feedback on issues under DOI review. Use good judgement in understanding issues and work with compliance to prepare for discussions. Ability to represent claims as a knowledgeable SME.

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

• Background in commercial medical claims and recovery operations, with prior experience in a health plan or payer organization
• Proven ability to lead, influence, and collaborate across multiple functions and stakeholder groups
• Strong analytical skills with the ability to drive change and manage operations - highly preferred
• Ability to ensure risks associated with business activities are effectively identified, measured, monitored and controlled within accordance with compliance policies and procedures - highly preferred
• Six Sigma or Lean Management training/certifications - preferred

The opportunity to work at the cutting edge of health care delivery with a team that’s deeply invested in the community

• Work‑life balance, flexibility, and the autonomy to do great work
• 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

At Blue Cross NC, we take great pride in a fair and equitable compensation package that reflects market‑price and our starting salaries are typically planned near the middle of the range listed. Compensation decisions are driven by factors including experience and training, specialized skill sets, licensure and certifications and other business and…