Manager, Claims

Job Description

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
• 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 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 ASO Claims Subject Matter Expert and single point of contact for performance monitoring and troubleshooting
• Represent Claims Operations to ASO executives providing data, reports, analytics, and expertise routinely and on demand
• Support ASO Channel lead serving as the Claims ASO Subject Matter Expert and acting as single point of contact both internally and to the ASO for all Claims, Claims Recovery, and Claims Accounting related escalations

• 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.
• Bonus:
  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.

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

• 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
• Learn more

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 organizational needs. Our base salary is part of a robust Total Rewards package that includes an Annual Incentive Bonus*, 401(k) with employer match, Paid Time Off (PTO), and competitive health benefits and wellness programs.

* Based…