Claims Manager

Centivo; Buffalo (AL); Hybrid; USD 110,000 - 140,000; Full time

Job summary

Centivo in Buffalo, NY is seeking a Claims Manager to lead oversight of health claims processing for self-funded employer groups. You will manage claim supervisors, SMEs, and Analysts, set productivity goals, and monitor quality metrics while coordinating with cross-functional teams.

You will guide policy development, ensure SLA alignment, mentor staff, and deliver reports on claim inventory, turnaround times, and performance.

Qualifications

• 5+ years of experience with self-funded health care plans.
• Experience in a Third Party Administrator (TPA) environment.
• Experience with automated claim adjudication systems; El Dorado-Javelina preferred.
• Strong leadership and coaching abilities.
• Excellent written and verbal communication skills.
• Ability to manage vendor relationships and SLA compliance.

Responsibilities

• Demonstrate knowledge of benefit administration for self-funded plans.
• Support client relationships and implementation with issue resolution.
• May be a direct contact for clients, vendors, or providers.
• Ensure claims are processed and paid per benefit plans, pricing and authorizations.
• Manage inventory of claims against standard service level agreements (SLAs).
• Educate and mentor staff, set performance plans for those below expectations.
• Provide reports on claim inventory, production, turnaround lag, and quality metrics.
• Develop policies for operations and ensure staff compliance.
• Establish annual goals for staff aligned with organizational strategy.
• Collaborate on projects including testing for system implementations/upgrades.
• Oversee vendor and network partner relationships and related processes.
• Perform other duties as deemed essential.

Skills

Leadership and people management

Strong communication skills

Process development and improvement

Health insurance benefit admin knowhow

Relationship management

Analytical reporting

Tools

MS Word

Excel

Outlook

PowerPoint

Salesforce

El Dorado-Javelina

Job description

We exist for workers and their employers -- who are the backbone of our economy. That is where Centivo comes in -- our mission is to bring affordable, high-quality healthcare to the millions who struggle to pay their healthcare bills.

Summary of role:

As a Claims Manager, you will be responsible for the oversight and management of health claims processing for our self-funded employer groups. You will have direct management of claim supervisors, subject matter experts (SME), Claims Analysts who are responsible for the accurate processing and ancillary support of health care claims on behalf of the employer plan and members benefits and will set and monitor productivity goals and claim quality metrics. You will work across functional teams within Centivo to manage and resolve dependencies impacting backlog and turnaround time goals and with Quality/Training and System Configuration teams to ensure standard processes are established, policies are enforced, and issues are mitigated through collaborative decision making.

Responsibilities Include:

Working under guidance of the Director- Claims Management, you will:

• Demonstrate knowledge and understanding of benefit administration for self-funded healthcare plans

• Directly support the client relationship and implementation process by being a collaborative partner with teams responsible for client facing issue resolution

• May be a direct point of contact for clients, vendors or providers that require relationship owners

• Ensure that metrics are established and monitored to ensure claims are processed and paid in accordance with benefit plans, pricing agreements, and required authorizations

• Manage the inventory of claims against standard service level agreements (SLA's)

• Educate and mentors claims staff and to ensure proper application of client benefit plans to claims processed, at the required quality and production metrics, including establishing performance plans for those falling below expectations with appropriate coaching and mentoring to achieve improvement

• Provides reports to department leaders on claim inventory, production, turn-around lag, and quality metrics

• Create work plans to reduce claim inventory, including management of over-time hours that are appropriately monitored for cost effectiveness

• Develop policy and procedures to ensure that benefit plans and claim standards are properly administered; assists in developing policies and procedures for operations, and monitors claim staff for compliance

• Accountable for positively influencing the morale of the department employees, including setting achievable goals, fostering teamwork by involving team in the design/implementation of solutions to problems

• Responsible to establish annual goals for staff that align with organization strategies and personal growth and can provide timely and constructive feedback on performance

• A liaison for the claims on various projects and/or initiatives including testing needs to support system implementations and/or upgrades

• May also have direct ownership and responsibility for vendor and network partners, invoice management for vendors, overpayment and recovery process, subrogation and appeals management, external pricing strategies, and continual process improvement initiatives

• Performs other duties as deemed essential and necessary.

Qualifications:

Required Skills and Abilities:

• Proficient experience in MS Word, Excel, Outlook, and PowerPoint required

• Salesforce experience is a plus, high efficiency with tool is a bonus

• Understanding of health insurance benefit administration in a Self-Funded environment

• Strong leadership and team management skills, with the ability to communicate effectively with others

• Demonstrate abilities with process development and improvement as well as change management

• Ability to read and understand various forms, documentation, files, and information with the department

• Excellent verbal and written communication skills; ability to speak clearly and concisely, conveying complex or technical information in a manner that others can understand, as well as ability to understand and interpret complex information form others, including but not limited to reimbursement policy standards

• Strong interpersonal skills, establishing rapport and working well with others

Experience:

• At least 5 years of experience with self-funded health care plans, and experience in a Third Party Administrator (TPA) environment

• Must have prior experience with a highly automated and integrated claim adjudication system, El Dorado-Javelina preferred but not required.

Preferred Qualifications:

• Experience Health Rules Payer and/or El Dorado-Javelina

• Advanced proficiency in Excel

• Experience managing Claims inventory

Work Location:

• An ideal candidate would be assigned to the Buffalo Office with ability to work from home

• Remote available for a strong fit

Centivo Values:

• Resilient - This is wicked hard. There is no easy button for healthcare affordability. Luckily, the mission makes it worth it and sustains us when things are tough. Being resilient ensures we don't give up.

• Uncommon - The status quo stinks so we had to go out and build something better. We know the healthcare system. It isn't working for members, employers, and providers. So we're building it from scratch, from the ground up. Our focus is on making things better for them while also improving clinical results - which is bold and uncommon.

• Positive - We care about each other. It takes energy to do hard stuff, build something better and to be resilient and unconventional while doing it. Because of that, we make sure we give kudos freely and feedback with care. When our tank gets low, a team member is there to be a source of new energy. We celebrate together. We are supportive, generous, humble, and positive.

Who we are:

Centivo is an innovative health plan for self-funded employers on a mission to bring affordable, high-quality healthcare to the millions who struggle to pay their healthcare bills. Anchored around a primary care based ACO model, Centivo saves employers 15 to 30 percent compared to traditional insurance carriers. Employees also realize significant savings through our free primary care (including virtual), predictable copay and no-deductible benefit plan design. Centivo works with employers ranging in size from 51 employees to Fortune 500 companies. For more information, visit centivo.com.

Headquartered in Buffalo, NY with offices in New York City and Buffalo, Centivo is backed by leading healthcare and technology investors, including a recent round of investment from Morgan Health, a business unit of JPMorgan Chase & Co.