Director, Claims Management – Ancillary Services

🔥 0 minutes ago

🇺🇸 United States – Remote

💵 $135k - $145k / year

⏰ Full Time

🔴 Lead

👔 Director

🦅 H1B Visa Sponsor

This company has sponsored H1B visas in the past.

👻 Ghost score 1%

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Centivo

WebsiteLinkedInAll Job Openings

201 - 500 employees

Founded 2017

🏥 Healthcare

🛡️ Insurance

⚕️ Healthcare Insurance

Healthcare • Insurance • Healthcare Insurance

Centivo is an innovative health plan provider for self-funded employers that focuses on delivering high-quality healthcare at an affordable cost. The company believes in the power of primary care to improve health outcomes and reduce costs. Centivo offers plans with free primary care, no deductibles, and low, predictable copays, thereby encouraging members to utilize their health benefits without financial burden. The plans are curated to meet stringent price and quality standards, promoting a strong relationship with primary care providers and integrating virtual care options. Centivo's approach is designed to reduce overall medical expenses while enhancing the healthcare experience for both employers and employees.

📋 Description

• 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

🎯 Requirements

• 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

🏖️ Benefits

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