Director, Provider Service & BlueCard Claims

Responsibilities

• Direct end‑to‑end BlueCard claims processing, adjustments, and financial recovery activities across commercial, government, and inter‑plan lines of business, leveraging data‑driven analytics to inform decisions and execution.
• Develop the strategic vision and key processes for the provider contact center, prioritizing support delivered through vendors, plan-to-plan, and PSA contact channels by business impact
• Partner with Operational leads and workforce management to supplement strategy with the development of budgets, staffing models, and operational performance standards
• Direct and improve Strategic Provider Services offering, maintaining close relationships with key (Platinum) providers including use of site visits to inform provider service strategy and resolve escalated claims and service issues
• Oversee support of non-platinum providers through virtual contact centers while providing oversight for vendor relations. Ensure plan-to-plan contacts are handled in line with BCBSA standards and service level expectations
• Communicating with managers and team leads on the provider service strategy and align on operational changes necessary for execution
• Resolve complex escalations and contribute to training development to maintain and improve service delivery
• Monitor and review service performance ensuring that provider service agreements are met
• Report operational updates to the Claims AVP and Operations VP; serve as a subject matter expert for provider service
• End to end inventory management to align with all regulatory, Internal, external and other applicable processing guidelines and timeliness expectations; includes evaluating and adjusting all processing guidelines as required to meet customer expectations.
• What You Bring
• Bachelor's degree or advanced degree (where required)
• 10+ years' experience in Health Care Delivery and Operations
• In lieu of degree, 12+ years of experience in related field.
• Deep health plan claims and service expertise.
• 5+ years of progressive leadership experience.
• Bonus Points
• Deep expertise in BlueCard (Out-of-Area) claims operations, including Host/Home plan processing, inter-plan coordination, and compliance with Blue Cross Blue Shield Association guidelines.- highly preferred
• Strong analytical skills with the ability to drive transformational, consumer centric change while managing operations - highly preferred
• Six Sigma/Continuous improvement experience - highly preferred
• What You'll Get
• The opportunity to work at the cutting edge of health care delivery with a team that's deeply invested in the community.
• Work-life balance, flexibility, and the autonomy to do great work.
• Medical, dental, and vision coverage along with numerous health and wellness programs.
• Parental leave and support plus adoption and surrogacy assistance.
• Career development programs and tuition reimbursement for continued education.
• 401k match including an annual company contribution
• Learn more
• Salary Range
• *Based on annual corporate goal achievement and individual performance.
• $143,616.00 - $229,786.00

Requirements

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Benefits

Additional Information

Job Description As Director, Provider Service, you will play a key role in shaping and advancing the strategic vision for provider customer service. This leadership position empowers you to guide team leaders, drive support initiatives that meet high contractual and service standards and nurture a dynamic culture of excellence. You'll have the opportunity to analyze financial and service results, implementing meaningful strategies that enhance performance and deliver real value to the organization.

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