Director Claims Management Ancillary Services (CMAS)

We exist for workers and their employers -- who are the backbone of our economy. That is where Centivo comes in -- our mission is to bring affordable high-quality healthcare to the millions who struggle to pay their healthcare bills.

Summary of role:

The Director Claims Management Ancillary Services (CMAS) owns the strategy performance and compliance of Centivos claims ancillary functions with particular emphasis on the Plan Documents function. This role directly manages the Plan Documents Manager and the CMAS Manager and is accountable for the accuracy timeliness and regulatory compliance of Centivos plan documents -- including SBCs SPDs SMMs and amendments -- as well as the performance of claims audit appeals escalations recoveries subrogation and NSA functions.

The Director translates departmental and organizational strategy into executable plans builds a high-performing and accountable team and serves as the operational authority for CMAS and Plan Documents with clients brokers agents TPAs and stop loss carriers.

Responsibilities Include:

Plan Documents Strategy & Compliance

Own the strategy quality and regulatory compliance of Centivos plan document function including Summary Plan Descriptions (SPDs) Summary of Material Modifications (SMMs) plan amendments and Summary of Benefits and Coverage (SBCs)

Ensure plan document processes and content remain current with the Employee Retirement Income Security Act (ERISA) the Internal Revenue Code HIPAA the Medicare Secondary Payer Act (MSP) COBRA the Affordable Care Act (ACA) and the Womens Health and Cancer Rights Act (WHCRA)

Establish document governance standards review workflows and quality checkpoints to ensure plan documents are accurate complete and audit-ready across all clients and plan types

Partner with Legal Compliance Configuration and Client Success to translate client implementations plan changes and regulatory updates into accurate plan document output

Serve as the escalation point for complex plan document issues client-specific plan design questions and stop loss carrier document submissions

Champion adoption and continuous improvement of plan document tools and technology (e.g. PDM) to improve accuracy throughput and client experience

CMAS Operational Leadership

Own end-to-end performance of CMAS functions -- claims audit appeals escalations recoveries subrogation and No Surprises Act (NSA) -- ensuring accuracy compliance and adherence to service-level agreements

Establish and monitor operational and quality KPIs across CMAS and Plan Documents using data to identify trends and risks and to report performance to department leadership

Direct workforce and capacity planning across both functions including inventory management resource allocation and overtime oversight to balance cost efficiency with service performance

Drive process improvement workflow standardization and automation and AI-enabled enhancements across CMAS and plan document workflows

Oversee development and enforcement of policies and procedures to ensure consistent administration of CMAS and plan document standards

People Leadership & Cross-Functional Collaboration

Directly manage the Plan Documents Manager and CMAS Manager providing coaching performance feedback and development aligned to Centivos leadership behaviors

Set clear performance expectations and measurable goals for both teams aligned to organizational priorities and hold managers accountable for results

Foster a culture of accountability collaboration and engagement across the CMAS and Plan Documents teams involving staff in problem-solving and solution design

Represent CMAS and Plan Documents in cross-functional meetings client calls and discussions with brokers agents TPAs and stop loss carriers serving as the operational authority for these functions

Model and reinforce Centivos leadership behaviors -- Communicate Clarify Coach Connect and Customize -- through daily interactions and team management practices

Perform other duties as deemed essential and necessary

Qualifications:

Required Skills and Abilities:

7 years of experience in employee benefits compliance plan document administration or healthcare claims operations at a TPA health plan or benefits consulting firm

5 years of leadership experience managing managers supervisors or teams including experience overseeing plan document compliance or claims ancillary functions

Deep knowledge of ERISA the Internal Revenue Code HIPAA MSP COBRA the ACA and WHCRA as they apply to employer-sponsored welfare benefit plans

Demonstrated experience overseeing plan document drafting and management (SBCs SPDs SMMs) in a self-funded or TPA environment

Demonstrated experience overseeing claims audit appeals recoveries subrogation NSA or quality assurance functions in a regulated environment

Strong data literacy; ability to interpret operational and quality metrics and translate findings into action plans

Experience partnering with Legal Compliance Configuration and Client Success teams to resolve cross-functional dependencies

Bachelors degree required; paralegal certification or advanced degree in a relevant discipline preferred

Preferred Qualifications:

Employee benefits paralegal background or equivalent experience in plan document creation and management

Experience with Phia Groups PDM portal or similar plan document management systems

Experience with claims adjudication systems (e.g. Javelina Health Rules Payer or similar)

Experience leading or contributing to a claims system implementation or transformation

Experience in client-facing roles or working closely with account management teams on claims or plan document issues

Work Location:

This position is remote

Who we are:

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. For more information visit .

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.

Required Experience:

Director