Supervisor Claims
Blue Cross and Blue Shield Association - Harrisburg, PA
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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." Organizes and directs the efforts of the Unit utilizing both automated and manual processing systems in a timely and effective manner. Participates in the planning of Unit and Department goals and motivates staff to meet these goals. Acts as a knowledgeable resource for internal and external questions regarding the Facets Claims Processing Application and/or related claims systems. The supervisor is responsible for the planning, directing and controlling of the activities of Claims personnel in providing timely, accurate and cost-effective claims processing. Responsibilities and Qualifications * Coordinate and oversee processing and special projects for assigned area. Monitors workflow and inventory to remain compliant with BCBSA & legislative requirements (i.e. Act 68, ERISA), group performance guarantees and MTM standards. Participate in the development and implementation of appropriate inventory & performance strategies. Maintains and prepares reports of unit performance statistics. * Understand the processing procedures for the area of responsibility and answer claims processing and system questions. Review unusual or complex claim processing exceptions to make appropriate processing determinations. * Provide timely feedback to direct reports on no less than a monthly basis for productivity and quality.. Coach employees as needed. Follow company policies when performance coaching or corrective action is required. Complete performance evaluations by the due date established by Human Resources. * Ensure that Claims Operation and Company rules and regulations are enforced consistently. Be familiar with the Corporate and Department policies to effectively supervise the unit. * Identify and discern processing and/or configuration issues. Communicate issues with supporting details and examples to the Facets Technical Analysts. Pursue resolution of processing and configuration issues through the appropriate channels. Follow up to ensure issues are resolved in a timely manner or interim processing procedures are developed and implemented so as to not delay the processing of claims. * Consistently assess current procedures to determine effectiveness. Recommend improvements/alternatives and develop a high-level plan to test and implement such recommendations. Participate in the planning process to develop strategies to meet department and corporate performance goals and training. * Participate in the preparation of the Unit's annual budget to estimate required staff and other controllable expenses to meet department and corporate goals. Report monthly on budget variances. * Promote communication through meetings for information sharing, projects, problem solving and training. Establish effective working relationships with other Capital Blue Cross areas such as Customer Service, Internal Audit, Provider Relations, Clinical Management, Account Administration, Quality Assurance, etc. * Perform other tasks as assigned by the Manager, Director and/or Senior Director (e.g., special projects, information/research gathering and written reports). Skills: * Demonstrated verbal and written communication skills in order to effectively motivate staff and establish good working relationships with internal and external personnel. * Familiar with project management techniques, production planning and control, performance measurement methods and Human Resources policies necessary to oversee unit processing in order to meet unit/department goals. Knowledge: * Knowledge of the medical benefit programs including, but not limited to PPO, POS, HMO, Traditional, Comprehensive, SeniorBlue HMO and PPO, Medicare Supplemental and Consumer Driven Health products. * Knowledge and experience in the operation of various software packages (i.e., Microsoft Office). * Knowledge of Facets processing guidelines and procedures for items such as, PPO, POS, Managed Care, Traditional, ASHN, Account specific, Complaints, Grievances and Appeals, Refunds, Medicare, and OPL/COB. * Knowledge of overall Facets system functionality, Workflow functionality and the Claims Processing and Customer Service applications, in particular. Knowledge of the Image System, Optical Character Recognition (OCR) functionality & other web applications relevant to the Operational processing environment. * Familiar with overall Capital Blue Cross operations and policies, particularly BlueCard, Customer Service, COB/OPL, Clinical Management, Network, Provider Relations and Account Administration. Experience: * 3 years Claims experience. * One to two years in a lead position is preferred. * Preferred Coordination of Benefits/Subrogation experience. Education and Certifications: * Must possess a high school diploma and a minimum of five years experience in an Operational processing environment and/or a 4-year degree. 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 diverse and 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.
Created: 2024-10-13