Manager - Claims Operations & Optimization
About The Position
At Blue Cross Blue Shield Global SolutionsSM (BCBS Global SolutionsSM), we make it easy for people and organizations to access and pay for healthcare abroad. By combining digital innovation with human-centered care, we go above and beyond for our customers and deliver an international healthcare experience that’s simple, efficient and human. Whether our customers live, work, travel or study abroad, we give them the confidence and peace of mind to embrace every journey and say “yes” to new possibilities. You’re a claims operations leader who delivers consistently reliable quality today while building smarter, more efficient operations for tomorrow. You bring a strong command of claims processing and adjustment workflows, paired with the curiosity and drive to modernize how work gets done. Solving complex problems, improving outcomes and building strong partnerships across service, technology and operations? That’s where you do your best work. You know that great claims experiences depend on accuracy, speed and seamless collaboration. You’re also excited and ready to shape what’s next.
Requirements
- You have a Bachelor’s degree or equivalent combination of education and experience.
- You bring 5+ years of progressive experience in claims operations within healthcare or insurance.
- You have 2+ years of people leadership or team management experience.
- You have experience with international claims, digital claims solutions, automation, EDI, or adjudication platforms.
- You have strong expertise in claims processing, adjustments, and pended claims management.
- You’ve supported or led process improvement, operational optimization, or transformation initiatives.
- You’re analytical, collaborative, and motivated by continuous improvement.
Nice To Haves
- You are certified in Lean, Six Sigma, or similar process improvement certification.
Responsibilities
- Lead day-to-day claims operations with a focus on adjustments, claims cases and pended claims workflows.
- Ensure accurate, timely resolution of complex claims issues, escalations and exceptions.
- Design and execute strategies to reduce pended claim volume and aging by identifying root causes and driving sustainable process improvements.
- Monitor and manage operational performance metrics including turnaround time, accuracy, inventory, aging and quality.
- Ensure compliance with regulatory requirements, payer contracts and internal policies.
- Support audits, regulatory reviews and internal assessments as needed.
- Serve as the primary liaison between Claims and the Global Service Center to ensure strong operational alignment.
- Design and operationalize a second-level service model that supports real-time claim adjustments, documentation outreach and member/provider communications.
- Define workflows, roles, and escalation paths to improve speed, accountability and resolution quality.
- Partner closely with GSC leadership to reduce friction, prevent rework and improve the overall customer experience.
- Analyze service-related claim trends and implement improvements that strengthen responsiveness and first-contact resolution.
- Lead initiatives to improve claims quality, accuracy and first-pass resolution across all lines of business.
- Monitor quality trends, identify root causes of errors and implement corrective actions to reduce rework and adjustments.
- Partner with audit, training and operational leaders to strengthen quality controls and promote continuous improvement.
- Drive consistency in claims handling practices to improve outcomes and reduce variability.
- Play a key leadership role in enterprise claims transformation and digital modernization initiatives.
- Partner with IT, vendors and cross-functional teams to enhance automation, workflows and system capabilities.
- Identify opportunities for straight-through processing and reduced manual intervention.
- Lead data-driven process improvement efforts aligned with industry best practices.
- Support testing, implementation and change management to ensure successful adoption of new processes and technologies.
- Lead, coach and develop a high-performing team through clear expectations, ongoing feedback and growth-focused support.
- Foster a collaborative, accountable and customer-first always culture.
- Support workforce planning, training and succession efforts to build long-term capability and resilience.
Benefits
- Competitive base pay + annual bonus
- Competitive medical plans
- Telemedicine available
- Paid parental leave
- Employee assistance and wellness support 24/7
- Free international healthcare coverage
- Hybrid work model
- Work abroad arrangements available
- Generous PTO accrual program with carry-over option
- 9 paid holidays in addition to one floating holiday and one volunteer day
- Tuition reimbursement
- Career/Learning and development opportunities
- 401(k) with generous company match
- Pet insurance offerings
- Identify theft and legal coverages available
- Emphasis on well-being (Virtual well-being platform, monthly mindfulness events, and giveaways)
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What This Job Offers
Job Type
Full-time
Career Level
Manager
