Senior Manager, Claims Systems

Collective Health • Plano, TX

9d • $110,000 - $171,875 • Hybrid

About The Position

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

The position oversees claims system operations and technical performance, including EDI transaction ingestion and error resolution, accumulator research and reconciliation, system defect triage, RTB gap identification, and adjudication pend-rule configuration. It also serves as a technical operational subject matter expert, partnering with external health plan stakeholders and internal teams to improve data exchanges, resolve defects, and advance automation and operational consistency.

The role leads, coaches, and develops specialized teams and team leads, setting performance expectations, delegating effectively, and holding teams accountable. 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.

Requirements

• 10 or more 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 EDI 837I/837P claims transactions, investigate ingestion rejections, resolve return-file errors, and maintain data integrity across claims 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.
• Independently 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 clear performance expectations, delegate effectively, and hold leaders and teams accountable for results.
• Address performance concerns directly, 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 employees' 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