Resp & Qualifications
The Claims Manager oversees and manages the claims handling process in order to meet Provider contracted response times. Track production, error trending, develop workflow procedures and take corrective action on claim system issues. Assist in backlog reduction, Provider contact on claim issues, Provider/provider education, and interdepartmental communication to expedite claim handling.
Essential Duties and Responsibilities
Daily supervision of Claims staff (onsite and remote)
Inventory management and load balancing (daily):
Daily review of inbound claims, distribution of claims when necessary
Re-direction of work to accommodate time away from work, special projects, meetings, etc.
Management of workflows and improvements
Troubleshooting of defects and root cause analysis.
Communication to Analysts, Customer Service, Eligibility of improvements needed to reduce adjustments
Updating of document deficiencies to reduce adjustments
Distribution and monitoring of pended claims to ensure they are worked in a timely manner
Reduction of pends through process improvement where applicable
Daily, weekly, and monthly claim reports to Leadership team
Policy and procedure documentation:
Organization and upkeep of new and existing claim payment policies and procedures.
Creation of new procedural documents whenever necessary, as evident from questions arising from Analysts, QA, CSRs or leadership team
Conversion of meeting minutes into P&P document updates or new documentation whenever necessary
Month end renewals management:
Monitoring of renewals for potential stop loss resolution
Communication to Analysts of steps needed to move stop loss cases through month end process
Facilitation of month end meeting
Documentation and updates of month end process steps in policy and procedure document
Claim error analysis and coaching of analysts
Performance evaluation and coaching (annually, or as needed)
Processing of complex claims, or to reduce claim backlog
Other duties as directed by Director of Claims or VP of Operations
Education, Experience and Qualifications
Associate’s or Bachelor’s degree with at least 3 to 5 years managing a claims department and 7 to 8 yrs. experience processing claims
CPT coding (certification a plus)
Knowledge, Skills and Abilities
Ability to give direction and training on extensive claim research, problem analysis and claim payments.
Demonstrated ability to work independently, and establish and accomplish team goals
Investigative, decision-making, problem solving, interpersonal, and organizational skills required.
Knowledge of ICD-9 (and ICD-10)
Ability to solve practical problems dealing with a variety of concrete variables in situations where only limited standardization exists
Analytical and detail oriented, but able to discern big picture and act accordingly
Excellent written and oral communication skills
Proficiency in Microsoft Word, PowerPoint, and Outlook
Intermediate to advanced experience with Excel including Pivot Tables and formulas
Microsoft Access and SQL skills a plus
Department: MD Medicaid -CONFIGURATION
Equal Employment Opportunity
CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.
Hire Range Disclaimer
Actual salary will be based on relevant job experience and work history.
Where To Apply
Please visit our website to apply: www.carefirst.com/careers
Please apply before: 7/7/21
Federal Disc/Physical Demand
Note: The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs.
The associate is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The associate must frequently talk and hear. Weights up to 25 pounds are occasionally lifted.
Sponsorship in US
Must be eligible to work in the U.S. without Sponsorship
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