Manager, Medicare Claims

Blue Cross and Blue Shield of North Carolina

3d • $98,092 - $156,947

About The Position

The Manager, Medicare Claims, oversees end-to-end claims services for provider segments, meeting business goals. This role sets performance targets, manages claims processing and financials, handles submissions, refunds, and recoveries, and ensures claims accounting and reporting. Collaboration with claims leadership ensures alignment with customer needs and contracts.

Requirements

• 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.

Nice To Haves

• 1-2 years of Medicare and Medicaid experience or a highly regulated operational environment – highly preferred
• Strong analytical skills with the ability to drive change and manage operations
• Ensure risks associated with business activities are effectively identified, measured, monitored and controlled within accordance with compliance policies and procedures

Responsibilities

• 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.
• Serve as Medicare Claims Subject Matter Expert and single point of contact for performance monitoring and troubleshooting.
• Represent Claims Operations on monthly CMS calls with CMS Account manager answering questions, providing status updates and expertise routinely and on demand.
• Ability to engage as requested by Compliance with regulatory entities, especially CMS on monthly calls and serve as an internal point of contact to prepare feedback on issues under CMS review. Use good judgement in understanding issues and work with compliance to prepare for discussions. Ability to represent claims as a knowledgeable SME.

Benefits

• 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
• Based on annual corporate goal achievement and individual performance.

What This Job Offers

• Job Type: Full-time
• Career Level: Manager
• Number of Employees: 5,001-10,000 employees