Claims Director

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, ... (truncated, view full listing at source)