Responsibilities:
- Oversees enrollment and billing operations across Medicare Advantage, Medicare Supplement, CHIP, and ACA products, ensuring accurate eligibility, premium billing, and member maintenance.
- Directs reconciliation, quality, and performance monitoring activities, identifying trends, risks, and opportunities for improvement.
- Leads audit readiness and regulatory support efforts, including responses to CMS audits and compliance reviews.
Regulatory & Compliance:
- Ensures compliance with federal and state regulations, including CMS and applicable program requirements, through oversight of policies and procedures.
- Manages Medicare Advantage appeals and grievances to ensure timely, compliant resolution in accordance with CMS requirements.
- Partners cross-functionally with Compliance, Claims, Customer Service, and other stakeholders to resolve complex operational issues.
Leadership & Strategy:
- Provides leadership, strategic direction, and cross-functional coordination to support accurate enrollment and compliant appeals resolution.
- Drives process improvement initiatives to enhance accuracy, efficiency, member experience, and regulatory outcomes.
- Manages staff and utilizes strong analytical, decision-making, and problem-solving capabilities to oversee diverse product lines.
Capital Blue Cross
Capital Blue Cross is a health insurance company and independent licensee of the Blue Cross Blue Shield Association that promises to go the extra mile for its team and community. It is consistently voted one of the 'Best Places to Work in PA,' fosters a flexible environment prioritizing health and wellbeing, and invests heavily in employee training and continuing education.