Manager Claims-Local

Position Description

Base pay is influenced by several factors including a candidate’s qualifications, relevant experience, and anticipated contributions to meet the needs of the business, along with internal pay equity and external market driven rates. The salary range displayed has not been adjusted for geographical location. This range has been created in good faith based on information known to Capital Blue Cross at the time of posting and may be modified in the future. Capital Blue Cross offers a comprehensive benefits packaging including Medical, Dental & Vision coverage, a Retirement Plan, generous time off including Paid Time Off, Holidays, and Volunteer time off, an Incentive Plan, Tuition Reimbursement, and more.At Capital Blue Cross, we promise to go the extra mile for our team and our community. This promise is at the heart of our culture, and it’s why our employees consistently vote us one of the “Best Places to Work in PA.” 

The Local Claims Manager is responsible for overseeing activities related to the processing of local commercial claims. The manager is responsible for the planning, directing and controlling of the activities of Claims personnel in providing timely, accurate and cost-effective claims processing. The Claims Manager will oversee claims examiners and claims adjustment staff to ensure timely, accurate processing of claims.

Responsibilities and Qualifications

• Develops implements and monitors qualitative and quantitative criteria for the evaluation of the department’s personnel and operation. Recommends and develops improved processes and procedures to monitor and meet departmental goals. Facilitates all performance appraisals and salary reviews for employees. Assists in resolution of production, inquiry response or personnel related problems. Develops skills of employees through discussion, instruction and delegation of appropriate responsibilities. Conducts routine meetings with claims staff to address corporate, departmental and unit issues.

• Assess and monitor the overall claims processing operation through the analysis of automated and manual reporting and take appropriate corrective action to ensure departmental goals are met. Determines personnel requirements necessary to provide quality processing in accordance with department and corporate goals and objectives.

• Assists in preparation of the annual budget and corporate plans to estimate resource expenditures required to meet departmental and corporate goals. Represents the department on various committees or task force projects as assigned. Reviews the development and implementation of ongoing departmental training efforts and recommends enhancements as appropriate.

• Performs research and analysis relative to current or future claims functions and presents results and/or recommendations in written and statistical report.

• Analyzes the effects of policy and procedural changes upon the department and on our customers. Maintain an up-to-date understanding of the Facets system and make recommendations for modifications. Communicates in written and verbal form to the marketplace, various Plan personnel and other BlueCross and BlueShield Plans regarding Claims topics.

Skills:

• Ability to effectively communicate in written and verbal form to varied audiences on both simple and complex issues.
• Ability to coordinate and direct activities of each Unit to meet quality and quantity standards. Ability to plan, organize, delegate and prioritize work in order to maintain an overall efficient operation.
• Ability to analyze automated and/or manual processing problems and design, develop and assist in implementing enhancements. Includes the ability to prioritize multiple change requests.
• Ability to lead motivates, appraise and develop personnel.

Knowledge:

• Knowledge of the Claims processing, policies and procedures and Capital Blue Cross product design.

• Knowledge of general coding processes and procedures.

• Knowledge of the Facets claims processing system, including the XC database; Imaging and OCR software and systems; and complete end to end knowledge of CBC’s electronic claim submission flows.

• Knowledge of Plan organization, personnel and major functions of the operating areas.

• Familiar with Budget theory and methods.

• Knowledge of production planning and control, especially in the area of fluctuating workload demands.

Experience:

• 5 years claims experience in the health insurance industry.
• 1 year staff, team lead or project lead experience

Education and Certifications:

• Prefer a bachelor’s degree from an accredited college or university.

Location: 

• This position is classified hybrid, which requires onsite work on Tuesdays and Wednesdays. 

Physical Demands:

• While performing the duties of the job, the employee is frequently required to sit, use hands to finger, handle and feel, and talk, hear, and see.
• The employee must be able to work over 40 hours per week.
• The employee must occasionally lift and/or move up to 5 pounds.

 

 

About Us

We recognize that work is a part of life, not separate from it, and foster a flexible environment where your health and wellbeing are prioritized. At Capital you will work alongside a caring team of supportive colleagues, and be encouraged to volunteer in your community.  We value your professional and personal growth by investing heavily in training and continuing education, so you have the tools to do your best as you develop your career. And by doing your best, you’ll help us live our mission of improving the health and well-being of our members and the communities in which they live.