Claims Manager

Centivo•Buffalo, NY

11d•$95,000 - $100,000•Hybrid

About The Position

Centivo is hiring a Claims Manager to oversee health claims processing for self-funded employer groups. The role manages claim supervisors, subject matter experts, and Claims Analysts responsible for accurate claims processing and ancillary support, and establishes and monitors productivity goals and quality metrics. The Claims Manager works across Centivo teams to resolve issues affecting claims backlogs and turnaround times, and partners with Quality/Training and System Configuration teams to establish standard processes, enforce policies, and mitigate issues. Working under the guidance of the Director- Claims Management, the Claims Manager supports client relationships and implementation, monitors claims against benefit plans, pricing agreements, authorizations, and service-level agreements, and leads staff development and performance management. The role also provides reporting and develops work plans and policies to support efficient, compliant claims operations. Depending on assigned responsibilities, the position may oversee vendor and network partners, vendor invoices, overpayment recovery, subrogation, appeals, external pricing strategies, and process improvement initiatives. The ideal candidate would be assigned to Centivo’s Buffalo office and have the ability to work from home. Remote work is available for a strong fit.

Requirements

At least 5 years of experience with self-funded health care plans.
Experience in a Third Party Administrator (TPA) environment.
Prior experience with a highly automated and integrated claim adjudication system.
Proficiency in MS Word, Excel, Outlook, and PowerPoint.
Understanding of health insurance benefit administration in a self-funded environment.
Strong leadership and team management skills, with the ability to communicate effectively.
Demonstrated ability in process development and improvement, as well as change management.
Ability to read and understand forms, documentation, files, and other information relevant to the department.
Excellent verbal and written communication skills, including the ability to convey complex or technical information clearly and understand and interpret complex information, including reimbursement policy standards.
Strong interpersonal skills, including the ability to establish rapport and work well with others.

Nice To Haves

Salesforce experience; high efficiency with the tool is a bonus.
El Dorado-Javelina claim adjudication system experience.
Experience with Health Rules Payer and/or El Dorado-Javelina.
Advanced proficiency in Excel.
Experience managing claims inventory.

Responsibilities

Demonstrate knowledge and understanding of benefit administration for self-funded healthcare plans.
Support client relationships and implementation by collaborating with teams responsible for client-facing issue resolution.
Serve as a point of contact for clients, vendors, or providers when relationship ownership is required.
Establish and monitor metrics to ensure claims are processed and paid according to benefit plans, pricing agreements, and required authorizations.
Manage claims inventory against standard service-level agreements.
Educate and mentor claims staff to ensure correct application of client benefit plans and required quality and production standards; establish performance plans and provide coaching and mentoring when expectations are not met.
Provide department leaders with reports on claim inventory, production, turnaround lag, and quality metrics.
Create plans to reduce claims inventory, including appropriately monitoring overtime hours for cost effectiveness.
Develop and help implement policies and procedures for proper benefit-plan and claims administration, and monitor staff compliance with claims standards.
Influence department morale by setting achievable goals and fostering teamwork, including involving the team in designing and implementing solutions.
Establish annual staff goals aligned with organizational strategies and personal growth, and provide timely, constructive performance feedback.
Liaise on claims-related projects and initiatives, including testing for system implementations and upgrades.
As assigned, manage vendor and network partners, vendor invoice management, overpayment and recovery processes, subrogation, appeals, external pricing strategies, and process improvement initiatives.
Perform other duties deemed essential and necessary.