The Manager Claims & Eligibility oversees workflows for claims and eligibility operations. The primary functions of the team are claims adjudication and eligibility management. This position is responsible for ensuring efficient processes and for ensuring procedural and reference materials are maintained. Additionally, this position is responsible for making sure all team members are compliant with all departmental and organizational standards and requirements.

Key Performance Indicators (KPIs) and Service Level Agreements (SLAs) (75%)

• Consistently meet and/or exceed department KPIs and SLAs.
• Consistently meet and/or exceed goals for claims and eligibility as defined by external audit entities.
• Drive team results based upon established departmental quality and production performance metrics.
• Ensure compliance with BCBS submission grid.
• Administer claims and eligibility inventory/workflow through the entire life cycle to ensure timely processing and ensure compliance with all regulatory agencies.

Leadership and Operational Performance (25%)

• Promote operational excellence though development, implementation and management of departmental monitoring tools, controls, policy and procedures.
• Provide supervisors with clear direction and coaching regarding accountability pertaining to departmental goals and productivity.
• Work with other departments to assist in the development of new programs/processes to bring greater efficiency and improve the quality of Claim and Eligibility operations.
• Communicate with appropriate staff to ensure identified problems are resolved.
• Works closely with HR in regards to hiring, onboarding, training, and performance management of team members.

SUPERVISORY/MANAGEMENT SCOPE

This manager role will have direct responsibility for 4.0-5.0 FTE including: supervisors, refund coordinator, and auditor. Additionally, indirect responsibility for 35-40 FTE claims and eligibility team members.

• Bachelor's Degree in Business, Healthcare Administration or related field.
• 2-3 years of experience leading teams of people in a supervisor or manager capacity.
• Experience with claims processing, managing multiple priorities and successful adherence to key performance indicators and service level agreements.
• Knowledge of eligibility functions and downstream impacts.