Manager, Claims

Blue Cross and Blue Shield of North Carolina•Remote Flex - North Carolina, NC

2d•$107,901 - $172,642

About The Position

The Manager, Claims implements an end-to-end service model across provider segments and ensures delivery against business targets. The role sets performance and process targets within assigned customer segments to support high levels of claims processing, claims financial processing, and customer service. It manages claims submissions, refunds, and recoveries across all lines of business for assigned customer segments, collaborates with claims leadership on customer segments and contractual obligations, and oversees claims accounting and financial reporting. The manager supports the Finance Division by overseeing the gathering, preparation, analysis, and reconciliation of financial data for compliance with accepted accounting principles and standards. The role leads team leads and staff, manages operational and financial recovery activities, and acts as a claims subject matter expert and point of contact for ASO performance monitoring, troubleshooting, and escalations. It also represents Claims Operations to ASO executives with data, reports, analytics, and expertise.

Requirements

Bachelor's degree or advanced degree where required; in lieu of a degree, 10+ years of experience in a related field.
8+ years of experience in a related field.
Experience leading claims teams and performance management.
Understanding of claims systems and processing workflows.
Data analytics and reporting experience.

Nice To Haves

Demonstrated claims operations experience in a regulated claims environment, such as Medicare, government programs, or similar.
Experience with Facets or similar claims platforms is strongly preferred.

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 gathering, preparing, analyzing, and reconciling financial data to ensure compliance with accepted accounting principles and standards.
Research and resolve banking issues.
Participate in projects to improve or facilitate claims processing, recovery, and accounting functions.
Manage financial recovery activities, including refunds and collections.
Manage team leads and staff, driving work volume to maintain high utilization and engagement.
Resolve complex claims appeals by coordinating with stakeholders for certain 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 improvement, and identify 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 the Claims ASO 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 the ASO Channel lead as the Claims ASO subject matter expert and point of contact internally and to the ASO for Claims, Claims Recovery, and Claims Accounting escalations.