Manager - Medicare Advantage Claims Operations

2 months ago

Detroit, Michigan, United States Blue Cross Blue Shield of Michigan Full time
Responsible for planning, organizing and managing an assigned business unit.

Operate within broad objectives to ensure optimum utilization of resources; adapt business unit plans and priorities to address resource and operational challenges.

Evaluate policies, procedures and business unit goals to make decisions and solve problems. * Manage activities of a department including, but not limited to planning, problem solving, staff development and communication.

* Manage the evaluation of new and existing business processes to identify areas of opportunity and execute on business unit objectives, supporting continuous improvement.

* Lead, direct, evaluate and develop the work of assigned employees. * Responsible for special projects, programs and initiatives to ensure successful delivery of business outcomes.

* Provide effective and efficient solutions to complex business problems * Ensure that day to day business unit operations align with organizational objectives.

Qualifications * Bachelor's Degree in a related field is required. Master's Degree in a related field is preferred. * Five (5) years of experience in a related field is required. * Previous experience leading projects and/or teams is required. * Ability to effectively lead, coach and develop team members. * Ability to work effectively in a team environment. * Strong organizational, planning, analytical, and problem-solving skills. * Working knowledge of corporate organizational structures, including functional responsibilities. * Strong verbal, written communication and interpersonal skills. * Ability to manage multiple priorities concurrently. * Ability to solve practical problems and deal with moving variables in situations with limited standardization and alignment. * Ability to interface and present to all levels of the organization. * Ability to build relationships and work collaboratively with cross-functional teams.

Departmental Preferences * Must have working level knowledge of and experience with MA PPO and CMS Reimbursement regulations and Methodologies.

* Ability to Partner with Claims Operations, claim BPO, MA System Liaison Team and IT to ensure correct business outcomes * Manage resources responsible for Audits, including but not limited to those conducted by BCBSM Internal, CMS (Governmental), Large Key Accounts, Benefits, Financial Auditing Firms, and all other audits pertaining to MA PPO Business.

Previous audit experience preferred.

* Manage resources responsible for reviewing complex claims inquiries received from though-out the organization, including Servicing (member and provider), G & A, Provider Engagement, Executive Services, etc.

Previous MA PPO Claims experience required. * CMS guidelines working level knowledge preferred. * Responsible for Group RFP responses. Previous RFP experience preferred. * Manage resources responsible for Inter-Plan Services (ITS) Releases. * Manage resources responsible for Provider Data Maintenance in the ikaSystem, including verifying provider credentials.

All qualified applicants will receive consideration for employment without regard to, among other grounds, race, color, religion, sex, national origin, sexual orientation, age, gender identity, protected veteran status or status as an individual with a disability.

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