Director, Claims Management – Ancillary Services

This is a fully remote position, open to applicants in United States.

📋 Description

• Take ownership of the strategy, quality, and regulatory compliance for Centivo's plan document function, which includes SPDs, SMMs, plan amendments, and SBCs.

• Ensure that the processes and content related to plan documents are up-to-date with ERISA, the Internal Revenue Code, HIPAA, MSP, COBRA, the ACA, and WHCRA.

• Establish governance standards for documents, review workflows, and implement quality checkpoints.

• Collaborate with Legal, Compliance, Configuration, and Client Success teams to accurately translate implementations, plan changes, and regulatory updates into plan document outputs.

• Act as an escalation point for intricate plan document issues, client-specific plan design inquiries, and submissions to stop loss carriers.

• Advocate for plan document tools and technologies, such as PDM, to enhance accuracy, throughput, and the client experience.

• Oversee the complete performance of claims audit, appeals, escalations, recoveries, subrogation, and NSA functions.

• Set up and monitor operational and quality KPIs, reporting performance to department leadership.

• Manage workforce and capacity planning, inventory management, resource allocation, and overtime oversight.

• Promote process enhancement, workflow standardization, automation, and AI-driven improvements.

• Supervise policies and procedures for consistent CMAS and plan document administration.

• Directly oversee the Plan Documents Manager and CMAS Manager.

• Establish performance expectations and measurable goals; mentor managers and hold them accountable.

• Encourage accountability, collaboration, and engagement among the CMAS and Plan Documents teams.

• Represent CMAS and Plan Documents at cross-functional meetings and client discussions with brokers, agents, TPAs, and stop loss carriers.

• Exemplify Centivo's leadership behaviors: Communicate, Clarify, Coach, Connect, and Customize.

• Carry out other essential duties as required.

⛳️ Requirements

• A minimum of 7 years of experience in employee benefits compliance, plan document administration, or healthcare claims operations at a TPA, health plan, or benefits consulting firm.

• At least 5 years of leadership experience managing managers, supervisors, or teams, specifically in overseeing plan document, compliance, or claims ancillary functions.

• Extensive knowledge of ERISA, the Internal Revenue Code, HIPAA, MSP, COBRA, the ACA, and WHCRA relevant to employer-sponsored welfare benefit plans.

• Proven experience in overseeing the drafting and management of plan documents, including SBCs, SPDs, and SMMs, within a self-funded or TPA environment.

• Demonstrated experience in managing claims audit, appeals, recoveries, subrogation, NSA, or quality assurance functions in a regulated setting.

• Strong data literacy with the capability to interpret operational and quality metrics and convert findings into actionable plans.

• Experience in collaborating with Legal, Compliance, Configuration, and Client Success teams to address cross-functional dependencies.

• Bachelor's degree is mandatory.

• Background as an employee benefits paralegal or equivalent experience in creating and managing plan documents.

• Familiarity with Phia Group's PDM portal or comparable plan document management systems.

• Experience with claims adjudication systems like Javelina, Health Rules Payer, or similar platforms.

• Experience in leading or contributing to a claims system implementation or transformation project.

• Experience in client-facing roles or working closely with account management teams on claims or plan document matters.

• Must be authorized to work in the United States; Centivo does not provide sponsorship for work authorization visas.

🏝️ Benefits

• Equity offerings.

• Bonus opportunities.

• Health benefits (with some employer contributions).

• Paid time off (PTO).