Manager of Medicare Claims & Customer Service

Job Summary:

This individual will plan, coordinate, and supervise the day-to-day operations of the Claims Customer Service call center. The manager is responsible for leading customer service representatives, ensuring timely and accurate responses to customer, agent, and provider inquiries, and maintaining service levels that support operational goals and customer satisfaction. Primary responsibilities include workforce management, call quality monitoring, escalation support, training, reporting, and continuous improvement of call center processes.

For this key role, a top priority is to ensure consistent service delivery, adherence to established procedures, effective issue resolution, and a strong culture of customer service.

They must have strong knowledge of call center operations, customer service best practices, performance metrics, workforce planning, and issue escalation processes. They must apply strong analytical, organizational, technical, and problem-solving skills on a daily basis to support a high-volume service environment.

Key Responsibilities:

Essential duties and responsibilities include but are not limited to the following:

• Call Center Operational Oversight: Manage day-to-day operations of the Claims Customer Service call center to ensure adherence to company policies, established procedures, service level agreements, and customer experience standards. Ensure timely and successful service delivery to internal and external customers.
• Team Leadership: Lead, coach, and mentor customer service representatives and supervisors. Foster a culture of accountability, collaboration, continuous improvement, and customer-centric service delivery.
• Training and Development: Develop training programs, call handling resources, scripting, and job aids for new hires and ongoing skill enhancement. Ensure team members are equipped with the product knowledge, system knowledge, communication skills, and escalation protocols needed to support customers effectively.
• Process Improvement: Identify opportunities to improve call flow, reduce handle times, enhance first-call resolution, improve quality scores, and strengthen the overall customer experience through process redesign, automation, and best practices.
• Performance and Workforce Management: Monitor call volume, staffing levels, schedules, service levels, abandonment rates, quality results, and productivity metrics. Use reporting and trend analysis to allocate resources effectively and address performance gaps.
• Customer and Agent Support: Oversee the resolution of escalated customer, agent, and provider inquiries. Provide guidance on complex service issues, coordinate with internal departments as needed, and ensure timely follow-through and clear communication.
• Quality and Risk Management: Monitor call quality, documentation practices, complaint trends, and operational risks. Develop mitigation strategies, implement controls, and ensure customer interactions align with company standards and applicable requirements.
• Ensure all department procedures are followed.

Qualifications:

• Minimum 2-4 years of experience in life and health insurance operations, customer service, or call center management
• Bachelor’s degree in Business Administration, Insurance, Finance, or a related field
• 3+ years of experience leading customer service, call center, or insurance operations teams
• Experience managing call center performance metrics, including service levels, call volume, abandonment rates, quality monitoring, and productivity standards
• Experience developing customer service procedures, call scripts, training materials, and escalation protocols
• Experience in a managed healthcare, Medicare supplement, or insurance customer service environment preferred, with a clear understanding of Medicare procedures, compliance requirements, and related principles.

Key Responsibilities:

• 
  
• Proven experience in leadership and team management within a complex operational environment

Skills:

• Analytical Skills: Strong analytical skills with the ability to interpret call center data, identify trends, monitor service performance, and make data-driven decisions that improve customer experience and operational efficiency.
• Process improvement: Experience in process improvement methodologies such as Six Sigma or Lean is preferred
• Quality Monitoring: Regularly review call quality, documentation accuracy, customer feedback, and service trends to identify coaching opportunities and improve customer interactions.
• Compliance: Maintain awareness of applicable insurance, privacy, and customer communication requirements to ensure customer service activities remain compliant with company standards and regulatory expectations.
• Technical Proficiency: Proficiency in using Microsoft Office Suite
• Attention to Detail: Exceptional attention to detail to ensure accurate documentation, clear communication, and consistent follow-through on customer inquiries.
• Communication: Excellent verbal and written communication skills, with the ability to interact effectively with internal and external stakeholders.
• Integrity: Strong commitment to ethical standards in healthcare billing and fraud prevention.
• Time Management: Ability to handle multiple tasks efficiently, prioritize work, and manage time efficiently in a high-volume environment.
• Collaboration: Ability to work collaboratively with internal and external stakeholders.
• Leadership: Strong leadership abilities with experience managing cross-functional teams.
• Risk Management: Strong risk assessment and mitigation skills to identify potential challenges and develop contingency plans.
• Budget Management: Experience in budgeting, cost estimation, and financial forecasting.
• Problem-Solving: Advanced problem-solving skills to quickly resolve project issues and roadblocks.
• Customer Focus: Commitment to understanding and delivering on client expectations.

Work Environment / Physical Requirements:

The work environment is a standard office setting with typical office equipment. This role involves professional collaboration with colleagues and clients. Responsibilities may involve extended periods of sitting, occasional walking between departments or meeting rooms, and periodic standing, reaching, stooping, and lifting office items weighing up to 25 pounds.