Senior Manager, Claims Systems

New Listings • San Francisco, TX

8d • Hybrid

About The Position

Collective Health is seeking an experienced Senior Manager, Claims Systems to lead specialized teams responsible for Accumulator Operations, EDI 837 Ingestion & File Resolution, and Claims Performance & Resolution (CPR). The role requires deep technical knowledge of end-to-end claims adjudication, EDI transactions, benefit hierarchy, health plan configuration, and claims system logic. The Senior Manager identifies systemic gaps, translates complex operational issues into technical requirements, and partners with Product and Engineering to deliver sustainable solutions.

This is a hybrid position based out of the San Francisco, Lehi, or Plano office, with an expectation of working in the office at least two to three weekdays per week. Pay ranges by location are $137,500–$171,875 in San Francisco, $110,000–$137,500 in Lehi, and $121,000–$151,250 in Plano. The actual offer depends on factors including geographic location, qualifications, experience, and internal equity. The role is eligible for 135,000 stock options and benefits including health insurance, 401(k), and paid time off.

Requirements

• 10+ years of experience in health insurance operations, third-party administration (TPA), or health plan claims systems, including direct management experience or equivalent practical experience.
• Strong technical understanding of EDI 837 transactions, clearinghouse exchanges, file ingestion, system coding and logic, and error resolution.
• Demonstrated expertise in claims adjudication workflows, benefit hierarchy, health plan configuration, pend rules, and identifying systemic processing gaps.
• Experience with accumulator reconciliation, cross-benefit transfers, over-accumulation research, and synchronization.
• Ability to independently diagnose complex system defects, identify root causes, and translate findings into actionable solutions for Product and Engineering.
• Experience partnering with technical and operational stakeholders to prioritize system improvements, resolve defects, and reduce manual processing.
• Proven ability to develop technical teams, delegate responsibilities, establish accountability, make difficult decisions, and lead through organizational change.

Responsibilities

• Oversee institutional and professional claims transactions (837I/837P), investigate ingestion rejections, resolve return-file errors, and maintain data integrity across claims processing workflows.
• Lead accumulator research, reconciliation, transfers, and over-accumulation remediation across medical and pharmacy benefit integrations.
• Oversee system defect triage, Run-The-Business (RTB) gap identification, and adjudication pend rule configuration and maintenance.
• Evaluate end-to-end claims adjudication, benefit hierarchy, plan configuration, and system logic to identify processing gaps, configuration defects, and opportunities to improve automated adjudication.
• Investigate complex claims processing failures, distinguish operational, configuration, EDI, and system defects, and drive appropriate resolution.
• Serve as a technical operational subject matter expert for Product and Engineering, translating system gaps into actionable requirements, prioritized fixes, and automation opportunities.
• Partner with medical networks, PBMs, and clearinghouses to ensure accurate data exchanges, timely issue resolution, and SLA adherence.
• Establish and monitor operational KPIs, defect trends, processing timelines, and SLA performance to drive accountability and continuous improvement.
• Identify opportunities to reduce manual intervention, eliminate recurring defects, and improve claims processing accuracy and scalability.
• Maintain documentation supporting adjudication logic, system workflows, compliance, and operational consistency.
• Lead, coach, and develop specialized claims systems teams and team leads, building technical expertise and operational ownership.
• Establish performance expectations, delegate effectively, and hold leaders and teams accountable for results.
• Address performance concerns, navigate difficult conversations, and make decisions that balance operational priorities and organizational needs.

Benefits

• Health insurance
• 401(k)
• Paid time off
• 135,000 stock options
• Professional development through internal mobility opportunities, mentorship programs, and courses tailored to employee interests
• Flexible work arrangements and a supportive work-life balance

What This Job Offers

• Job Type: Full-time
• Career Level: Senior
• Education Level: No Education Listed