Claims Director
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 Operations serves as the operational and strategic bridge between VP-level leadership and front-line claims management. This role owns the end-to-end performance of the claims operation, translating company and departmental strategy into executable plans while building a high-performing, accountable team. The Director is responsible for driving claims quality, speed, and scalability through disciplined inventory management, technology transformation, client experience excellence, and a strong learning culture.
Responsibilities Include:
Operational Leadership & Performance
Own the day-to-day operational performance of the claims department, including direct oversight of Claims Managers, Supervisors, SMEs, and Sr. Examiners
Support the strategy and execution of a roadmap to drive auto-adjudication rates
Establish, monitor, and enforce inventory management standards and workflows to ensure claims are processed within defined SLAs across all claim types and funding arrangements
Establish and track key metrics related to claims administration including payment accuracy; use data to set targets and drive continuous improvement
Create and execute work plans to reduce and sustain optimal inventory levels, including resource planning, overtime management, and capacity forecasting
Client Experience, Strategic Planning and Cross-functional Collaboration
Develop and own the claims department's client experience strategy, ensuring that operational execution consistently reflects Centivo's service commitments and differentiators
Establish feedback loops with client-facing teams to identify recurring claims impacting client satisfaction and translate findings into operational improvements
Serve as the claims operational owner of the system transformation from Javelina to HRP, partnering with Technology, Implementation, and Product teams to ensure a successful transition
Ensure claims processing continuity and quality throughout all phases of the transformation, with minimal disruption to SLAs, client commitments, and member experience
Partner with Quality and Training teams to design and maintain a curriculum that ensures consistent application of benefit plan knowledge, adjudication standards, and compliance requirements across all claims staff
Establish proficiency standards and competency checkpoints for all claims roles; use quality audit data and performance metrics to identify training gaps and adjust programs accordingly
Own the prioritization of claims projects and client needs, balancing competing demands across operational improvement initiatives, system transformation workstreams, and time-sensitive client escalations; communicate prioritization decisions clearly to leadership and cross-functional partners to ensure alignment and appropriate resource allocation
Represent the claims organization in cross-functional meetings, vendor discussions, client calls, and provider engagements, serving as the operational authority for claims-related topics and ensuring that commitments made externally are realistic, documented, and handed off effectively to the appropriate internal and external stakeholders
Lead a structured root cause analysis (RCA) program to identify, categorize, and resolve the underlying drivers of claims errors, including configuration issues, examiner knowledge gaps, system limitations, and process breakdowns
Partner with Quality, Configuration, and Product teams to close the loop on identified error trends, ensuring fixes are implemented, validated, and sustained over time
Drive continuous improvement in claims processing workflows, identifying manual touchpoints, redundant steps, and pend patterns that create friction and delay; redesign processes to reduce waste and improve throughput
Identify opportunities for process automation, workflow optimization, and technology leverage to improve scale and reduce unit cost in claims operations
Collaborate with Plan Configuration, Stop Loss, Quality, Provider Operations, and Member Operations teams to resolve cross-functional dependencies and drive aligned outcomes
Translate VP-level operational strategy into department-level goals, plans, and priorities; cascade direction clearly to managers and hold teams accountable for execution
People Leadership
Directly manage Claims Managers and provide coaching, performance feedback, and development support aligned to Centivo's leadership behaviors
Set clear performance expectations, establish measurable goals aligned to organizational priorities, and hold direct reports accountable for results
Model and reinforce Centivo's leadership skills and behaviors — Communicate, Clarify, Coach, and Connect — through daily interactions and team management practices
Foster a culture of accountability, execution rigor, and psychological safety within the claims department
Qualifications:
Required Skills and Abilities:
7 years of experience in healthcare claims operations at a third-party administrator
5 years of leadership experience managing claims teams, including direct management of managers or supervisors
Deep knowledge of self-funded health plan administration, claims adjudication, and healthcare payer compliance requirements
Demonstrated experience owning claims inventory management and driving measurable improvement in turnaround time and auto-adjudication performance
Experience leading or contributing significantly to a claims system implementation or transformation (experience with Javelina and/or HRP a plus)
Proven ability to develop and execute training strategies that drive quality and consistency across large claims teams
Strong data literacy; ability to interpret operational metrics, identify trends, and translate findings into action plans
Experience in client-facing roles or working closely with account management teams on claims-related issues
Familiarity with continuous improvement methodologies and process management principles
Leadership Skills:
Business Acumen – A keenness and quickness in understanding and dealing with a business situation (risks and opportunities) in a manner that is likely to lead to a good outcome. Critical to this is an ability to think beyond their own function.
Accountability & Execution – Taking ownership of actions, following through on commitments, actively carrying out tasks, monitoring progress, delivering results as promised, and being answerable for positive and negative outcomes.
Charisma - the ability to build rapport, tell and story and "hold a room"
Empathy/Humility - the ability to put oneself in the shoes of others, listen to others, understand others needs and be attentive to their feelings and thoughts, to build trust and an authentic connection to others.
Strategist Mindset - The ability see and articulate the bigger picture, thinking proactively and anticipating both opportunities and obstacles in the context of setting direction and maintain alignment to long-term company goals.
Systems Thinking– The ability to see and articulate the patterns, interconnections and interdependencies within a system
Process Orientation – The ability to see and articulate the sequential flow of activities, including anticipating impacts upstream and downstream when processes are changed.
Flexibility/Working through Ambiguity – Tendency to be energized by new experiences/perspectives, working with both data and fragmented information to arrive at practical, effective, actionable next steps.
People Manager Leadership Behaviors
Communicate – Managers discuss the company’s vision and strategies, the department’s direction and goals, and in times of crisis, what we know and don’t know to make sure team members know what they need to know.
Clarify – As managers, it’s up to us to clarify what good looks like. What do we expect? What do our clients, customers or colleagues need? If our teams are not performing as expected, managers must clarify expectations and ensure understanding.
Coach – Managers provide recognition and feedback; help team members find solutions to challenges; amplify good and filter weaker aspects of organizational culture and the work as they coach employees in their day-to-day performance and their growth and career development.
Connect – Managers help our teams see their collective purpose and how their work connects to the greater whole. We connect people within our company and network.
Customize –Managers must adapt how we delegate, how we clarify, how we coach, how we communicate and how we connect depending on the individual and task.
Centivo Values:
Resilient – This is wicked hard. There is no easy button for healthcare affordability. Luckily, the mission makes it worth it and sustains us when things are tough. Being resilient ensures we don’t give up.
Uncommon - The status quo stinks so we had to go out and build something better. We know the healthcare system. It isn't working for members, employers, and providers. So we're building it from scratch, from the ground up. Our focus is on making things better for them while also improving clinical results - which is bold and uncommon.
Positive – We care about each other. It takes energy to do hard stuff, build something better and to be resilient and unconventional while doing it. Because of that, we make sure we give kudos freely and feedback with care. When our tank gets low, a team member is there to be a source of new energy. We celebrate together. We are supportive, generous, humble, and positive.
Work Location:
This position may either work onsite in the Buffalo office or remotely
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 centivo.com.
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.