Director, Claims Management – Ancillary Services

🕒 Agosto 25

🇺🇸 Estados Unidos – Remoto (EUA)

💵 $135.000 - $145.000 / ano

⏰ Tempo Integral

🔴 Especialista

👔 Diretor

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Centivo

SiteLinkedInTodas as Vagas

201 - 500 funcionários

Fundada em 2017

🏥 Saúde

🛡️ Seguros

⚕️ Seguro de Saúde

Healthcare • Insurance • Healthcare Insurance

A Centivo é uma inovadora fornecedora de planos de saúde para empregadores auto-segurados que foca em entregar cuidados de saúde de alta qualidade a um custo acessível. A empresa acredita no poder do atendimento primário para melhorar os resultados de saúde e reduzir custos. A Centivo oferece planos com atendimento primário gratuito, sem franquias e co-pagamentos baixos e previsíveis, incentivando, assim, os membros a utilizarem seus benefícios de saúde sem sobrecarga financeira. Os planos são elaborados para atender a rigorosos padrões de preço e qualidade, promovendo um forte relacionamento com os provedores de atendimento primário e integrando opções de atendimento virtual. A abordagem da Centivo é projetada para reduzir as despesas médicas gerais, ao mesmo tempo em que melhora a experiência de saúde tanto para empregadores quanto para empregados.

Descrição

• Own the strategy, quality, and regulatory compliance of Centivo's plan document function, including SPDs, SMMs, plan amendments, and SBCs • Ensure plan document processes and content remain current with ERISA, the Internal Revenue Code, HIPAA, MSP, COBRA, the ACA, and WHCRA • Establish document governance standards, review workflows, and quality checkpoints • Partner with Legal, Compliance, Configuration, and Client Success to translate implementations, plan changes, and regulatory updates into accurate plan document output • Serve as escalation point for complex plan document issues, client-specific plan design questions, and stop loss carrier document submissions • Champion plan document tools and technology, including PDM, to improve accuracy, throughput, and client experience • Own end-to-end performance of claims audit, appeals, escalations, recoveries, subrogation, and NSA functions • Establish and monitor operational and quality KPIs and report performance to department leadership • Direct workforce and capacity planning, inventory management, resource allocation, and overtime oversight • Drive process improvement, workflow standardization, automation, and AI-enabled enhancements • Oversee policies and procedures for consistent CMAS and plan document administration • Directly manage the Plan Documents Manager and CMAS Manager • Set performance expectations and measurable goals; coach managers and hold them accountable • Foster accountability, collaboration, and engagement across CMAS and Plan Documents teams • Represent CMAS and Plan Documents in cross-functional meetings and client discussions with brokers, agents, TPAs, and stop loss carriers • Model Centivo's leadership behaviors: Communicate, Clarify, Coach, Connect, and Customize • Perform other essential duties as necessary

🎯 Requisitos

• 7 years of experience in employee benefits compliance, plan document administration, or healthcare claims operations at a TPA, health plan, or benefits consulting firm • 5 years of leadership experience managing managers, supervisors, or teams, including experience overseeing plan document, compliance, or claims ancillary functions • Deep knowledge of ERISA, the Internal Revenue Code, HIPAA, MSP, COBRA, the ACA, and WHCRA as they apply to employer-sponsored welfare benefit plans • Demonstrated experience overseeing plan document drafting and management, including SBCs, SPDs, and SMMs, in a self-funded or TPA environment • Demonstrated experience overseeing claims audit, appeals, recoveries, subrogation, NSA, or quality assurance functions in a regulated environment • Strong data literacy and ability to interpret operational and quality metrics and translate findings into action plans • Experience partnering with Legal, Compliance, Configuration, and Client Success teams to resolve cross-functional dependencies • Bachelor's degree required • Employee benefits paralegal background or equivalent experience in plan document creation and management • Experience with Phia Group's PDM portal or similar plan document management systems • Experience with claims adjudication systems such as Javelina, Health Rules Payer, or similar • Experience leading or contributing to a claims system implementation or transformation • Experience in client-facing roles or working closely with account management teams on claims or plan document issues • Authorized to work in the United States; Centivo does not sponsor work authorization visas

🏖️ Benefícios

• Offers equity • Offers bonus • Health benefits (some employer paid) • PTO