The Manager Claims Business Rules Configuration leads the strategy, design, and execution of claim system configuration to support accurate, efficient, and compliant claims processing.
This role oversees daily operations, optimizes configuration rules, drives process improvement, and ensures the successful delivery of configuration initiatives across all products and programs.
KEY RESPONSIBILITIES
Operational Leadership
Oversee daily operations and performance of the Claims Systems Configuration team.
Develop, track, and report on departmental KPIs.
Ensure accurate and optimized claims processing through strong data integrity and continuous process improvement.
Provide approval for configuration deployments, documentation, and training materials.
Maintain departmental audit controls and partner with Compliance to ensure readiness for internal or external audits.
Configuration Strategy and Execution
Lead the design and implementation of claim business rule configurations, including clinical and admin policy, benefit, provider, and authorization rules.
Manage change control, risk assessments, issue resolution, and progress reporting.
Support the refinement activities of configuration requests and design align with approved requirements.
Recommend system improvements to increase auto-adjudication rates and streamline claims processing.
Documentation, Training and Quality
Oversee development and maintenance of departmental work instructions, policies, and workflows.
Ensure effective training materials are created and maintained for configuration processes.
Conduct and oversee audits to ensure adherence to processes and documentation standards.
Team Leadership and Development
Motivate and guide the team to meet performance expectations and departmental goals.
Support Supervisors and Trainers in developing staff knowledge and capabilities.
Assist with personnel management activities, including hiring, performance evaluations, and disciplinary actions.
Provide escalation support for complex configuration or client issues.
Cross-Functional Collaboration
Partner with governance and process improvement teams to refine workflows and remove impediments.
Collaborate with internal teams to provide education on system configuration and support corrective action responses.
Ensure knowledge transfer across departments and support broader organizational initiatives.
Minimum Education, Licensure and Professional Certification
High school diploma required
Bachelor’s degree in healthcare or computer related field preferred
Minimum Experience Required
5+ years’ experience of business rule configuration in a claims adjudication platform, to include clinical and admin policy rules, provider contract rates and benefit management.
7+ years’ experience in healthcare claims life cycle
2+ years of supervisor experience
Skills
Proficiency in Excel, Word and Access, required. Advanced in Excel, preferred
Knowledge of SQL Data Query, Power BI, preferred
Proficiency in Claim Business Rule configuration in a claims adjudication platform, required
Knowledge healthcare IT claim adjudication systems, claims processing, healthcare data sets (ICD-10, CPT/HCPC, etc.)
Knowledge of Agile, Kanban, Jira board and dashboard management
Strong analytical and critical thinking skills, required
Strong decision-making skills, required
Strong aptitude for process improvement, required
Strong communication skills, required
Ability to supervise, multitask and work independently in a fast-paced environment are essential skills for this position
This role is also anticipated to be eligible to participate in an annual bonus plan.
At The Cigna Group, you’ll enjoy a comprehensive range of benefits, with a focus on supporting your whole health. Starting on day one of your employment, you’ll be offered several health-related benefits including medical, vision, dental, and well-being and behavioral health programs. We also offer 401(k), company paid life insurance, tuition reimbursement, a minimum of 18 days of paid time off per year and paid holidays. For more details on our employee benefits programs, click here.
About Evernorth Health Services
Evernorth Health Services, a division of The Cigna Group, creates pharmacy, care and benefit solutions to improve health and increase vitality. We relentlessly innovate to make the prediction, prevention and treatment of illness and disease more accessible to millions of people. Join us in driving growth and improving lives.Qualified applicants will be considered without regard to race, color, age, disability, sex, childbirth (including pregnancy) or related medical conditions including but not limited to lactation, sexual orientation, gender identity or expression, veteran or military status, religion, national origin, ancestry, marital or familial status, genetic information, status with regard to public assistance, citizenship status or any other characteristic protected by applicable equal employment opportunity laws.
If you require reasonable accommodation in completing the online application process, please email: SeeYourself@cigna.com for support. Do not email SeeYourself@cigna.com for an update on your application or to provide your resume as you will not receive a response.
The Cigna Group has a tobacco-free policy and reserves the right not to hire tobacco/nicotine users in states where that is legally permissible. Candidates in such states who use tobacco/nicotine will not be considered for employment unless they enter a qualifying smoking cessation program prior to the start of their employment. These states include: Alabama, Alaska, Arizona, Arkansas, Delaware, Florida, Georgia, Hawaii, Idaho, Iowa, Kansas, Maryland, Massachusetts, Michigan, Nebraska, Ohio, Pennsylvania, Texas, Utah, Vermont, and Washington State.
Qualified applicants with criminal histories will be considered for employment in a manner consistent with all federal, state and local ordinances.