Manager, Government Enrollment & Appeals
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Job Description
Manager overseeing enrollment and billing operations across Medicare Advantage and related programs at Capital Blue Cross. Leading compliance efforts and managing appeals and grievances for government programs.
Responsibilities:
- Oversees enrollment and billing operations across Medicare Advantage, Medicare Supplement, CHIP, and ACA products, ensuring accurate eligibility, premium billing, member maintenance, and ongoing operational performance.
- Leads Medicare Advantage appeals and grievances, ensuring timely, compliant resolution of member and provider appeals and grievances in accordance with CMS requirements.
- Ensures compliance with federal and state regulations, including CMS and applicable program requirements, through effective oversight of policies, procedures, controls, and regulatory reporting.
- Directs reconciliation, quality, and performance monitoring activities related to enrollment, billing, and Medicare Advantage appeals, identifying trends, risks, and opportunities for improvement.
- Leads audit readiness and regulatory support efforts, including responses to CMS audits, compliance reviews, and internal oversight activities related to enrollment, billing, and Medicare Advantage appeals and grievances.
- Partners cross‑functionally with Compliance, Claims, Customer Service, Sales, Product, Finance, IT, and other stakeholders to resolve complex operational issues and ensure enterprise alignment.
- Drives process improvement initiatives to enhance accuracy, efficiency, member experience, and regulatory outcomes across all assigned functions.
Requirements:
- 5 years’ experience in one or more of the following; enrollment, billing, reconciliation.
- 1 year of staff, team lead or project lead experience.
- Experience managing health insurance enrollment and billing operations.
- Experience overseeing Medicare Advantage Appeals and Grievances or related regulatory functions.
- Experience supporting compliance activities, audits, and operational improvement initiatives.
- Knowledge of enrollment and billing operations across Medicare and Individual market products.
- In‑depth understanding of Medicare Advantage appeals and grievance regulations and processes.
- Familiarity with CMS compliance, audit, and oversight expectations.
- Understanding of managed care operational workflows and cross‑functional dependencies.
- Bachelor’s degree in business, Health Care Administration, or a related field, or equivalent combination of education and experience.
Benefits:
- Medical, Dental & Vision coverage
- Retirement Plan
- Generous time off including Paid Time Off
- Holidays
- Volunteer time off
- Incentive Plan
- Tuition Reimbursement
- More
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