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 Centivo's 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 Centivo's 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 Centivo's 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 Women's 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 Centivo's 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 Centivo's 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

• Bachelor's 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 Group's 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 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.