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.

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.

• 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

• 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

• 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

• 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

• This position may either work onsite in the Buffalo office or remotely

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.