Manager, Claims Systems is responsible for the strategic oversight, operational performance, and continuous evolution of BCBS Global Solutions' claims administration systems. This role leads the Claims Systems Team and Repayment Specialists, ensuring system stability, operational readiness, and seamless integration of product, enrollment, and operational changes that impact claims processing.
This position serves as a liaison between Claims Operations, Enrollment, IT, Product, Finance, Compliance, and external system vendors. The Manager ensures all system configurations, enhancements, and process changes are accurately implemented, tested, and operationalized to support compliant, timely, and accurate claims adjudication and payment.
The role is accountable for meeting performance guarantees, service level agreements (SLAs), regulatory requirements, and internal control standards, while proactively identifying risks and driving system and process improvements.
ResponsibilitiesLeadership & Team Management- Lead, coach, and develop the Claims Systems Team and Repayment Specialists, including workload prioritization, performance management, succession planning, and employee development.
- Establish clear expectations and accountability to ensure team performance meets or exceeds contractual performance guarantees, SLAs, and internal KPIs.
- Foster a culture of operational excellence, collaboration, and continuous improvement.
Claims Systems Oversight- Provide end-to-end operational ownership of claims administration systems, including Actisure and related platforms.
- Oversee system configuration, maintenance, and controls, including benefit plans, provider setup, code sets, user roles, permissions, and claims correspondence.
- Ensure system functionality supports accurate, timely, and compliant claims processing across all products.
Operational Change & Product Enablement- Serve as the operational owner for all changes impacting claims systems, including new products, benefit updates, enrollment changes, and regulatory requirements.
- Ensure all product and operational changes are successfully translated into system requirements, configured accurately, and thoroughly tested prior to implementation.
- Act as the primary liaison between Enrollment and Claims to ensure alignment of eligibility, benefits, and claims adjudication logic.
Cross-Functional Partnership & Integration- Partner closely with IT, Product, Enrollment, Finance, Compliance, and vendors to coordinate system enhancements, upgrades, defect resolution, and integrations.
- Lead user acceptance testing (UAT), implementation readiness, and post-implementation validation for system changes.
- Serve as the primary operational point of contact for Claims Systems-related initiatives.
Financial & Repayment Oversight- Oversee claims system-related financial activities, including payment integrity, reconciliation support, and resolution of payment exceptions.
- Manage and support repayment processes, ensuring accurate identification, recovery, and tracking of overpayments.
Risk Management, Compliance & Controls- Ensure claims systems and related processes comply with regulatory requirements, contractual obligations, BCBSA standards, and internal policies.
- Support SOC audits and other internal and external audits, including documentation, testing, issue remediation, and control enhancements.
- Monitor system performance and operational trends to identify risks and implement corrective actions.
Reporting & Continuous Improvement- Develop and deliver operational reporting, dashboards, and status updates for leadership.
- Analyze system and operational data to identify opportunities for efficiency, accuracy, and scalability improvements.
- Drive process optimization initiatives that improve claims outcomes and operational resilience.
Requirements- Bachelor's degree or equivalent combination of education and relevant experience.
- 5+ years of experience in claims systems, claims operations, or healthcare insurance administration.
- 2+ years of people management experience.
- Demonstrated experience managing operational metrics, SLAs, and performance guarantees in a regulated environment.
- Experience working within a BCBS Health Plan environment preferred.
- Experience with Actisure or comparable claims administration systems.
- Strong people leadership, coaching, and change management skills.
- Deep knowledge of claims processing workflows and claims systems configuration.
- Ability to translate business and product requirements into operational system solutions.
- Strong analytical, problem-solving, and organizational skills.
- Exceptional cross-functional communication and stakeholder management abilities.
- Ability to manage multiple priorities in a deadline-driven environment.
- High attention to detail with a strong risk, control, and compliance mindset.
- Employee is required to have a minimum internet speed of 75 Mbps (standard high-speed internet access).
What You'll Get in Return- Competitive base pay plus annual bonus
- Competitive medical plans
- Telemedicine access
- Paid parental leave
- Employee assistance and wellness support available 24/7
- Free international healthcare coverage
Other Great Perks- Hybrid work model
- Work abroad arrangements available
- Generous PTO accrual program with carryover option
- Nine paid holidays, plus one floating holiday and one volunteer day
- Tuition reimbursement
- Career development and learning opportunities
- 401(k) with generous company match
- Pet insurance offerings
- Identity theft and legal coverage options
- Strong emphasis on well-being, including virtual wellness resources, monthly mindfulness events, and employee giveaways
