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Job Description

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.

What You’ll Do

+ 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.

What You Bring

+ 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 Points

+ 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

What You’ll Get

+ 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

Salary Range

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 on annual corporate goal achievement and individual performance._

$98,092.00 - $156,947.00

Skills

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

About Us

It's an exciting time to work at Blue Cross and Blue Shield of North Carolina (Blue Cross NC). Health care is changing, and we're leading the way. We offer more than health insurance our customers can count on. We’re committed to better health and better health care − in our communities and beyond. Our employees bring energy and creativity to the workplace, and it shows in our innovative approach to improving the health and well-being of North Carolinians.

Blue Cross NC is a fully taxed, not-for-profit company headquartered in Durham, North Carolina. We serve more than 4.3 million members, and we employ more than 5,000 people across the country who are passionate about making health care better for all.

Help us lead the charge for better health care by joining our award-winning team. Discover tremendous opportunities with us to do challenging and rewarding work. Opportunities that can lead you to a fulfilling career, work that can help others lead healthier, happier lives.

Authorization to Work in the United States

We use E-verify to confirm authorization to work in the United States. To learn more about E-Verify, including your rights and responsibilities, please visit E-Verify Overview (https://www.e-verify.gov/employees/e-verify-overview) for English or Visión General de E-Verify (https://www.e-verify.gov/es/empleados/vision-general-de-e-verify) for Español.

Request Accommodations

Blue Cross NC provides reasonable accommodations to applicants with disabilities. If you need a reasonable accommodation for any part of the application or hiring process, please notify HR at [email protected] .

For most roles, you can choose where to work - fully remote in one of the states listed below, in the office, or a hybrid of the two:

Alabama, Arizona, Arkansas, Colorado, Florida, Georgia, Idaho, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maryland, Michigan, Mississippi, Missouri, North Carolina, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Wisconsin, and Wyoming