Centivo

Business Analyst

• As a Claims Business Analyst, you will be responsible for triaging operational issues and leading projects and tasks to completion.
• You will use your claims adjudication experience and TPA background to triage operational concerns, vendor issues, and related claims issues.
• Familiarity with Centivo’s claims systems (Javelina and HealthRules Payer) is preferred.
• You will coordinate with all business units and external vendors during client implementations and conversions to determine requirements.
• This role ensures seamless integration between internal and vendor systems to support client requirements and operational workflows.
• Additionally, you will lead key projects and tasks identified to improve efficiency of Centivo’s Claim team.
• This role will use data analytics and other tools to identify areas of improvement needed in the business, scope out the initiative, and then lead the project through to completion.

Claims Business Analyst

General

• Adjudicating claims in assigned work queues based on Centivo’s written Policies and Procedures and the terms of the Summary Plan Documents (SPD’s) for Centivo’s clients.
• Diligently reviewing all system-generated edits which have been applied to claims in the Claims Adjustor’s assigned queues prior to releasing the claims to ensure benefits are being applied per the client’s SPD and client funds are being appropriately managed.
• When the Claims Adjustor believes there may be an issue or inconsistency in the interpretation of a Plan as the system is applying benefits, immediately route the claim to the Plan Build/System Configuration Team for resolution.
• When the Claims Adjustor is unable to resolve an edit based on the provider selection, the pricing and/or usual and customary discrepancies, immediately route the claim to the Provider Maintenance and/or Pricing teams for resolution.
• When the Claims Adjustor is unable to resolve an edit based on the information included with or attached to a claim, appropriately deny the claim for additional information, and generate correspondence to the participant or provider concisely explaining data needs. When such additional data is received, reopen the denied claim, and re-adjudicate based on the information.
• Maintain daily, weekly, and monthly required production levels documented in Claims Department Policies and Procedures.
• Participation in Departmental quality improvement efforts and bring forward process improvement suggestions that will improve efficiencies; question a process or policy that creates additional steps or work on the Claims Adjustor and suggest an alternative solution.
• Processes claims in accordance with established policies and procedures, contacting providers as needed, completing tasks under moderate supervision. Responsible for meeting the production and quality goals determined by the department leadership.
• Increased responsibilities, which may include assisting and mentoring less experienced team members, participating in various initiatives or projects within the Claims Delivery Team, documenting processes, performing advanced tasks, supporting high-dollar reviews, and overpayments/refunds.

Claims Adjustor

Learning and Development

• Develop, document, and maintain end-to-end claims business processes and workflows, ensuring clarity, accuracy, and usability for claims team members.
• Test claims workflows in Javelina and HRP to confirm processes function as designed and align with system configuration.
• Document all new claims processes step-by-step in Confluence for use by claims team members when adjudicating claims.
• Ensure documentation follows instructional design principles, is written in execution order, and includes screenshots as appropriate.
• Own and manage all existing claims process documentation in Confluence, (in addition to including creating new documentation) including editing existing content, archiving outdated materials, deleting obsolete content, etc.
• Build and maintain an intuitive documentation structure and search taxonomy to ensure ease of use and accessibility.
• Create training and reference materials for the Claims organization, including Processors, Auditors, Recovery Analysts (including NSA and Subrogation), Appeals.
• Design and deliver specialty claims training as needed to support new processes, system changes, or operational initiatives.
• As needed, support training and onboarding of Claims new hires.
• Partner with POP, Core Platform, and PMO teams to ensure claims process documentation aligns with new hire training, system configuration, and operational standards.
• Partner with POP as a subject matter expert to ensure claims process and adjudication content is accurate, providing quality review of new hire and enhanced training materials (including COB, adjustments, and corrected claims) and advising on the appropriate sequencing of content within new hire training.
• As needed, support claims operations by processing claims to assist with workload coverage and inventory management.

Claims Process Documentation, Training Specialist

Auditor

• Perform auditing of claims (for internal and external constituents), ensuring processing, payment, and financial accuracy by verifying all aspects of the claim have been handled correctly and according to both standard process and the client’s summary plan description.
• Completes reporting of audits finalized with decision methodology for procedural and monetary errors, which are used for quality reporting and trending analysis utilizing QA tools.
• Responsible to communicate corrections and adjustments to Claims Adjustors as identified on pre-payment audits, including high-dollar claims, and to verify corrections and adjustments are complete and accurate.
• Identify and escalate trends based on the quality reviews.
• Confer with Claims QA Lead, Claims Supervisors, Claim Managers, and/or Training Lead on any problematic issues warranting immediate corrective action.
• May investigate and research issues as required to create or improve standard processing guidelines and may participate in projects as a subject matter expert as needed.
• Perform any other additional tasks as necessary, including processing of claims, creating policies, training, and/or mentoring examiners through quality improvement plans.

Claims Auditor

Account Executive

• Serve as the primary executive point of contact and trusted advisor for a portfolio of large, national self-funded employer clients, owning the overall health, satisfaction, and growth of each relationship.
• Build and maintain multi-threaded relationships across client organizations — including C-suite, VP-level HR and Benefits leaders, and Finance stakeholders — through proactive, strategic engagement and a deep understanding of each client’s business priorities.
• Engage regularly with brokers, consultants, and benefits advisors aligned to national accounts, serving as a knowledgeable partner who reinforces the value of the Centivo solution at every touchpoint.
• Identify and drive opportunities to expand and deepen each client relationship, including increased enrollment, plan design enhancements, geographic growth, and new program adoption.
• Champion the client’s voice internally, advocating for their priorities across Centivo’s product, clinical, operations, and executive leadership teams.
• Lead the end-to-end renewal strategy for each national account, developing a client-specific approach that demonstrates measurable plan performance, validates savings against benchmarks, and positions Centivo for long-term retention.
• Design and deliver executive-level renewal presentations and business reviews that translate complex data — including claims analytics, cost benchmarking, clinical outcomes, and member engagement metrics — into a compelling, consultative narrative tailored to each client’s goals.
• Proactively identify and mitigate retention risks well in advance of renewal windows, drawing on stakeholder intelligence, utilization trends, and account health signals.
• Act as a strategic consultant to clients evaluating plan design changes, benefit expansions, or program enhancements, providing informed recommendations grounded in Centivo’s data and industry best practices.
• Represent the client success experience in finalist presentations and strategic sales pursuits, providing prospective national account clients with confidence in Centivo’s service model.
• Orchestrate a seamless, high-touch service experience for national accounts, coordinating across Centivo’s internal teams and vendor ecosystem to ensure exceptional delivery across all plan components — including member engagement, claims operations, PBM, provider network, and reporting.
• Establish clear operating rhythms, escalation protocols, and communication standards with each client, ensuring consistent and proactive account management throughout the plan year.
• Personally oversee the identification, tracking, and resolution of high-stakes client issues — including claims discrepancies, executive-level member escalations, and provider disputes — mobilizing the right resources and maintaining transparent client communication throughout.
• Leverage deep knowledge of self-funded plan administration and health plan operations to educate clients, contextualize plan data, and proactively address questions before they become concerns.
• Drive a data-informed account management approach, using plan analytics, population health trends, and benchmarking data to proactively surface insights and shape client conversations.
• Oversee the preparation and delivery of customized performance reporting and executive dashboards for national account clients, ensuring that data is presented clearly, accurately, and in a format that informs strategic decisions.
• Collaborate with internal analytics, clinical, and product teams to develop account-specific reporting that reflects each client’s defined success metrics and organizational priorities.
• Monitor emerging data signals — including high-cost claimants, utilization patterns, and care gap trends — and translate findings into actionable recommendations for plan sponsors.
• Serve as an ambassador for Centivo’s brand and mission within each national account, ensuring that the client’s internal teams, employees, and leadership understand the full value of the Centivo solution.
• Maintain a deep understanding of the competitive landscape for large, self-funded employers — including alternative funding models, TPA trends, and evolving broker/consultant expectations — to strengthen Centivo’s positioning within your book of business.
• Contribute insights from national account relationships to Centivo’s product and market strategy, serving as a key conduit between large client needs and internal roadmap priorities.

Claims Business Analyst

Claims Adjustor

Claims Process Documentation, Training Specialist

Claims Auditor

Client Success Executive – National Accounts