Claims Director
Centivo
full-time
Posted on:
Location Type: Remote
Location: United States
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Salary
💰 $135,000 - $145,000 per year
Job Level
About the role
- Own the day-to-day operational performance of the claims department, including direct oversight of Claims Managers, Supervisors, SMEs, and Sr. Examiners
- Support the strategy and execution of a roadmap to drive auto-adjudication rates
- Establish, monitor, and enforce inventory management standards and workflows to ensure claims are processed within defined SLAs across all claim types and funding arrangements
- Establish and track key metrics related to claims administration including payment accuracy; use data to set targets and drive continuous improvement
- Create and execute work plans to reduce and sustain optimal inventory levels, including resource planning, overtime management, and capacity forecasting
- Develop and own the claims department's client experience strategy, ensuring that operational execution consistently reflects Centivo's service commitments and differentiators
- Establish feedback loops with client-facing teams to identify recurring claims impacting client satisfaction and translate findings into operational improvements
- Serve as the claims operational owner of the system transformation from Javelina to HRP, partnering with Technology, Implementation, and Product teams to ensure a successful transition
- Ensure claims processing continuity and quality throughout all phases of the transformation, with minimal disruption to SLAs, client commitments, and member experience
- Partner with Quality and Training teams to design and maintain a curriculum that ensures consistent application of benefit plan knowledge, adjudication standards, and compliance requirements across all claims staff
- Establish proficiency standards and competency checkpoints for all claims roles; use quality audit data and performance metrics to identify training gaps and adjust programs accordingly
- Own the prioritization of claims projects and client needs, balancing competing demands across operational improvement initiatives, system transformation workstreams, and time-sensitive client escalations; communicate prioritization decisions clearly to leadership and cross-functional partners to ensure alignment and appropriate resource allocation
- Represent the claims organization in cross-functional meetings, vendor discussions, client calls, and provider engagements, serving as the operational authority for claims-related topics and ensuring that commitments made externally are realistic, documented, and handed off effectively to the appropriate internal and external stakeholders
- Lead a structured root cause analysis (RCA) program to identify, categorize, and resolve the underlying drivers of claims errors, including configuration issues, examiner knowledge gaps, system limitations, and process breakdowns
- Partner with Quality, Configuration, and Product teams to close the loop on identified error trends, ensuring fixes are implemented, validated, and sustained over time
- Drive continuous improvement in claims processing workflows, identifying manual touchpoints, redundant steps, and pend patterns that create friction and delay; redesign processes to reduce waste and improve throughput
- Identify opportunities for process automation, workflow optimization, and technology leverage to improve scale and reduce unit cost in claims operations
- Collaborate with Plan Configuration, Stop Loss, Quality, Provider Operations, and Member Operations teams to resolve cross-functional dependencies and drive aligned outcomes
- Translate VP-level operational strategy into department-level goals, plans, and priorities; cascade direction clearly to managers and hold teams accountable for execution
- Directly manage Claims Managers and provide coaching, performance feedback, and development support aligned to Centivo's leadership behaviors
- Set clear performance expectations, establish measurable goals aligned to organizational priorities, and hold direct reports accountable for results
- Model and reinforce Centivo's leadership skills and behaviors — Communicate, Clarify, Coach, and Connect — through daily interactions and team management practices
- Foster a culture of accountability, execution rigor, and psychological safety within the claims department
Requirements
- 7 years of experience in healthcare claims operations at a third-party administrator
- 5 years of leadership experience managing claims teams, including direct management of managers or supervisors
- Deep knowledge of self-funded health plan administration, claims adjudication, and healthcare payer compliance requirements
- Demonstrated experience owning claims inventory management and driving measurable improvement in turnaround time and auto-adjudication performance
- Experience leading or contributing significantly to a claims system implementation or transformation (experience with Javelina and/or HRP a plus)
- Proven ability to develop and execute training strategies that drive quality and consistency across large claims teams
- Strong data literacy; ability to interpret operational metrics, identify trends, and translate findings into action plans
- Experience in client-facing roles or working closely with account management teams on claims-related issues
- Familiarity with continuous improvement methodologies and process management principles.
Benefits
- Offers Equity
- Offers Bonus
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills & Tools
claims operationsclaims inventory managementclaims adjudicationdata literacyprocess automationworkflow optimizationcontinuous improvement methodologiesroot cause analysisperformance metricstraining strategy development
Soft Skills
leadershipcoachingcommunicationaccountabilitycollaborationproblem-solvingstrategic planningperformance feedbackpsychological safetyclient relationship management