Manager Medicare Claims, Appeals, and MSP

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.” 

This position is responsible for overseeing activities related to the processing of Medicare Advantage claims, Medicare Secondary Payer (MSP) claims, and Medicare Advantage appeals & grievances. The Manager will directly lead front-line staff and is responsible for daily performance in these areas. The Manager will also maintain productive and collaborative working relationships with internal and external partners.

Responsibilities and Qualifications

• Monitor team performance against Key Performance Indicators (KPIs) and develop action plans to maintain/improve performance
• Provide coaching and/or mentoring for front-line staff to ensure performance expectations and regulatory requirements are met
• Perform root cause analysis to Identify trends and top drivers related to member dissatisfaction and develop action plans to reduce member complaints
• Perform research and analysis relative to current or future claims functions and present recommendations for process improvements
• Monitor budget vs. actual expense reports each month and contribute to annual budget input process

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 productivity standards.
• Ability to lead, motivate, evaluate, and develop personnel.
•  Ability to collaborate cross-functionally and work effectively in a matrix environment

Knowledge:

• Knowledge of Managed Care and Medicare Advantage Contracting principles.
• Knowledge of Medicare Program and regulatory processes and requirements surrounding claims processing and appeals & grievance functions.
• Working knowledge of Microsoft Office Suite, including Word, Excel, Project Manager, and Power Point.

Experience:

• 5 years’ experience in one or more of the following areas: claims, appeals & grievances.
• 1 year staff, team lead or project lead experience
• Experience managing multi-disciplinary initiatives preferred.

Education and Certifications:

• High school diploma or equivalent.
• Prefer a Bachelor's Degree in Business or Health Care Administration.

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 and fingers, 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.