Manager Government Enrollment & Appeals

Position DescriptionBase 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.” This position is responsible for the overall management of enrollment and billing operations across all Government Programs, including Medicare Advantage, Medicare Supplement, CHIP, and ACA products. In addition, the role oversees Medicare Advantage appeals and grievances operations to ensure regulatory compliance, operational effectiveness, and consistent member experience. The manager provides leadership, strategic direction, and cross functional coordination to support accurate enrollment and billing, compliant appeals resolution, and audit readiness.Responsibilities And QualificationsOversees 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.SkillsStrong leadership and operational management skillsAbility to interpret and apply complex regulatory and program requirementsEffective written and verbal communication skillsAnalytical, decision‑making, and problem‑solving capabilitiesAbility to manage multiple priorities across diverse product linesKnowledgeKnowledge of enrollment and billing operations across Medicare and Individual market productsIn‑depth understanding of Medicare Advantage appeals and grievance regulations and processesFamiliarity with CMS compliance, audit, and oversight expectationsUnderstanding of managed care operational workflows and cross‑functional dependenciesExperience5 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 operationsExperience overseeing Medicare Advantage Appeals and Grievances or related regulatory functionsExperience supporting compliance activities, audits, and operational improvement initiativesEducation and CertificationsBachelor’s degree in business, Health Care Administration, or a related field, or equivalent combination of education and experiencePhysical DemandsWhile performing the duties of the job, the employee is frequently required to sit, use hands and fingers, talk, hear, and see. The employee may occasionally lift and/or move up to 5 pounds.About UsWe 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 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.Capital Blue Cross is an independent licensee of the Blue Cross Blue Shield Association. We are an equal opportunity employer and do not discriminate on the basis of race, color, religion, national origin, gender, sexual orientation, gender identity, age, genetic information, physical or mental disability, veteran status, or marital status, or any other status protected by applicable law.