Senior Manager, Claims Systems

Collective Health is reimagining health benefits through technology-driven, member-focused healthcare administration. We are seeking an experienced Senior Manager, Claims Systems to lead the specialized teams responsible for Accumulator Operations, EDI 837 Ingestion & File Resolution, and Claims Performance & Resolution (CPR).

This role requires deep technical knowledge of end-to-end claims adjudication, EDI transactions, benefit hierarchy, health plan configuration, and claims system logic. The ideal candidate can independently identify systemic gaps, translate complex operational issues into actionable technical requirements, and partner with Product and Engineering to drive sustainable solutions.

• EDI 837 Ingestion & File Resolution: Oversee institutional and professional claims transactions (837I/837P), investigate ingestion rejections, resolve return file errors, and maintain data integrity across claims processing workflows.
• Accumulator Operations: Lead accumulator research, reconciliation, transfers, and over-accumulation remediation across medical and pharmacy benefit integrations.
• Claims Performance & Resolution (CPR): Oversee system defect triage, Run-The-Business (RTB) gap identification, and adjudication pend rule configuration and maintenance.
• Adjudication & Configuration Expertise: 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.
• Root-Cause Analysis: Independently investigate complex claims processing failures, distinguish between 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.
• Demonstrate sound judgment, address performance concerns directly, navigate difficult conversations, and make decisions that balance operational priorities and organizational needs.

• 10+ years of experience in health insurance operations, third-party administration (TPA), or health plan claims systems, including direct management experience or equivalent practical experience.
• EDI & Claims Systems Expertise: Strong technical understanding of EDI 837 transactions, clearinghouse exchanges, file ingestion, system coding and logic, and error resolution.
• End-to-End Adjudication Knowledge: Demonstrated expertise in claims adjudication workflows, benefit hierarchy, health plan configuration, pend rules, and identifying systemic processing gaps.
• Accumulator Operations: Experience with accumulator reconciliation, cross-benefit transfers, over-accumulation research, and synchronization.
• Technical Problem-Solving: Ability to independently diagnose complex system defects, identify root causes, and translate findings into actionable solutions for Product and Engineering.
• Cross-Functional Collaboration: Experience partnering with technical and operational stakeholders to prioritize system improvements, resolve defects, and reduce manual processing.
• People Leadership: Proven ability to develop technical teams, delegate responsibilities, establish accountability, make difficult decisions, and lead through organizational change.

This is a hybrid position based out of our San Francisco, Lehi, or Plano office, with the expectation of being in office at least two to three weekdays per week. #LI-hybrid

The actual pay rate offered within the range will depend on factors including geographic location, qualifications, experience, and internal equity. In addition to the salary, you will be eligible for 135,000 stock options and benefits like health insurance, 401k, and paid time off. Learn more about our benefits at https://jobs.collectivehealth.com/benefits/.

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