[Hiring] Claims Manager @Centivo

Role Description

As a Claims Manager, you will be responsible for the oversight and management of health claims processing for our self-funded employer groups. You will have direct management of claim supervisors, subject matter experts (SME), and Claims Analysts who are responsible for the accurate processing and ancillary support of health care claims on behalf of the employer plan and members benefits.

• Set and monitor productivity goals and claim quality metrics.
• Work across functional teams within Centivo to manage and resolve dependencies impacting backlog and turnaround time goals.
• Collaborate with Quality/Training and System Configuration teams to ensure standard processes are established, policies are enforced, and issues are mitigated through collaborative decision making.

Responsibilities Include:

• Demonstrate knowledge and understanding of benefit administration for self-funded healthcare plans.
• Directly support the client relationship and implementation process by being a collaborative partner with teams responsible for client-facing issue resolution.
• May be a direct point of contact for clients, vendors, or providers that require relationship owners.
• Ensure that metrics are established and monitored to ensure claims are processed and paid in accordance with benefit plans, pricing agreements, and required authorizations.
• Manage the inventory of claims against standard service level agreements (SLA’s).
• Educate and mentor claims staff to ensure proper application of client benefit plans to claims processed, at the required quality and production metrics.
• Provide reports to department leaders on claim inventory, production, turn-around lag, and quality metrics.
• Create work plans to reduce claim inventory, including management of over-time hours that are appropriately monitored for cost effectiveness.
• Develop policy and procedures to ensure that benefit plans and claim standards are properly administered.
• Accountable for positively influencing the morale of the department employees.
• Responsible for establishing annual goals for staff that align with organization strategies and personal growth.
• A liaison for the claims on various projects and/or initiatives including testing needs to support system implementations and/or upgrades.
• May also have direct ownership and responsibility for vendor and network partners, invoice management for vendors, overpayment and recovery process, subrogation and appeals management, external pricing strategies, and continual process improvement initiatives.
• Performs other duties as deemed essential and necessary.

Qualifications

• Proficient experience in MS Word, Excel, Outlook, and PowerPoint required.
• Salesforce experience is a plus; high efficiency with the tool is a bonus.
• Understanding of health insurance benefit administration in a Self-Funded environment.
• Strong leadership and team management skills, with the ability to communicate effectively with others.
• Demonstrate abilities with process development and improvement as well as change management.
• Ability to read and understand various forms, documentation, files, and information with the department.
• Excellent verbal and written communication skills; ability to convey complex or technical information clearly.
• Strong interpersonal skills, establishing rapport and working well with others.

Requirements

• At least 5 years of experience with self-funded health care plans, and experience in a Third Party Administrator (TPA) environment.
• Must have prior experience with a highly automated and integrated claim adjudication system, El Dorado-Javelina preferred but not required.

Preferred Qualifications

• Experience with Health Rules Payer and/or El Dorado-Javelina.
• Advanced proficiency in Excel.
• Experience managing Claims inventory.

Work Location

• An ideal candidate would be assigned to the Buffalo Office with the ability to work from home.
• Remote available for a strong fit.

Centivo Values

• Resilient: This is wicked hard. There is no easy button for healthcare affordability. Being resilient ensures we don’t give up.
• Uncommon: The status quo stinks, so we had to go out and build something better.
• Positive: We care about each other and celebrate together. We are supportive, generous, humble, and positive.

Company Description

Centivo is an innovative health plan for self-funded employers on a mission to bring affordable, high-quality healthcare to the millions who struggle to pay their healthcare bills. Anchored around a primary care based ACO model, Centivo saves employers 15 to 30 percent compared to traditional insurance carriers.

Employees also realize significant savings through our free primary care (including virtual), predictable copay, and no-deductible benefit plan design. Centivo works with employers ranging in size from 51 employees to Fortune 500 companies.

Headquartered in Buffalo, NY with offices in New York City and Buffalo, Centivo is backed by leading healthcare and technology investors, including a recent round of investment from Morgan Health, a business unit of JPMorgan Chase & Co.