Claims Compliance Manager

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 Compliance Manager – Health Care Claims serves as the organization's subject matter expert (SME) on regulatory compliance matters pertaining to self-funded and level-funded health plan products administered through our Third Party Administrator (TPA) platform. This role is responsible for the end-to-end ownership of all mandated compliance reporting obligations, ensuring timely and accurate delivery to clients, plan sponsors, and all designated regulatory bodies. The ideal candidate brings deep operational knowledge of federal health care compliance requirements and thrives in a fast-paced environment where regulatory landscapes evolve frequently.

Responsibilities Include:

Regulatory Reporting & Filing

• Own and execute all CMS Section 111 (MSP) mandatory insurer reporting obligations, including coordination of data collection, submission, and error resolution; serve as the primary point of contact for CMS inquiries related to Section 111 reporting

• Manage RxDC (Prescription Drug and Health Care Spending) reporting under the Consolidated Appropriations Act (CAA), including both D2 Medical and P2 Medical data files; coordinate with pharmacy benefit managers (PBMs), stop-loss carriers, and internal teams to compile and submit accurate annual reports on behalf of plan sponsors

• Prepare and submit annual PCORI (Patient-Centered Outcomes Research Institute) fee filings for applicable self-funded plans, ensuring accurate calculation of covered lives and timely IRS Form 720 support

• Maintain a compliance reporting calendar and monitor all regulatory deadlines; proactively communicate status updates and filing confirmations to clients and internal stakeholders

Transparency & Disclosure Compliance

• Administer the Gag Clause Prohibition Attestation process under the CAA; collect required data, submit annual attestations to CMS/EEOC on behalf of plan sponsors, and maintain documentation of compliance

• Lead Transparency in Coverage (TiC) compliance efforts, including oversight of machine-readable file (MRF) production and publication requirements, and coordination with vendors and clients to meet all applicable mandates

• Support the development and maintenance of Preferred Networks disclosures and related plan document language to ensure alignment with regulatory standards

• Assist in the drafting and review of Summary Plan Descriptions (SPDs) and Summaries of Benefits and Coverage (SBCs), ensuring all documents reflect current plan designs, regulatory requirements, and plain-language standards

No Surprises Act (NSA) & IDR Support

• Serve as the internal SME on No Surprises Act (NSA) compliance, including Good Faith Estimate (GFE) requirements, Explanation of Benefits (EOB) standards, and balance billing protections

• Manage and coordinate NSA negotiations for out-of-network claims subject to the open negotiation process; partner with claims leadership and legal counsel to support Independent Dispute Resolution (IDR) proceedings, including submission preparation, documentation, and tracking of outcomes

Fraud, Waste & Abuse (FWA) Management

• Serve as a key contributor to the organization's Fraud, Waste & Abuse program, monitoring claims data for patterns, anomalies, and indicators of potential FWA activity across self-funded and level-funded plan populations

• Coordinate the flagging and suspension of suspect claims within the claims administration platform, ensuring appropriate holds, documentation, and chain-of-custody protocols are followed prior to escalation

• Liaise with the FBI, OIG, and other applicable law enforcement or regulatory agencies when suspected fraud rises to the level requiring external referral; prepare and submit referral documentation in accordance with agency requirements and organizational policy

• Maintain and distribute FWA activity reports to clients and appropriate parties, including summary findings, claim dispositions, and recovery outcomes where applicable

• Collaborate with Special Investigations Unit (SIU) resources, external audit partners, and stop-loss carriers on coordinated investigations

• Stay current on common FWA schemes in the health care claims space (e.g., upcoding, unbundling, phantom billing, provider fraud rings) and educate internal teams and clients accordingly

Client Advisory & SME Responsibilities

• Act as the primary claims compliance resource for clients, brokers, and consultants on all regulated reporting topics listed above; respond to inquiries with accuracy and in a timely manner

• Develop and deliver client-facing compliance guides, reporting summaries, deadline calendars, and educational materials to support plan sponsor understanding and accountability

• Distribute all required reports and filings to clients and agreed-upon parties (TPAs, stop-loss carriers, brokers, CMS, etc.) in accordance with compliant timelines and contractual obligations

• Monitor regulatory guidance from CMS, DOL, IRS, HHS, and other agencies; translate new requirements into actionable operational procedures for internal teams and clients

Internal Operations & Process Development

• Build, document, and continuously improve internal workflows, SOPs, and controls for each compliance program area

• Collaborate cross-functionally with Claims, IT, Account Management, Legal, and Finance to ensure data integrity and operational readiness for all compliance deliverables

• Identify and escalate compliance risks proactively; recommend corrective action plans as needed

• Support audit requests and regulatory examinations related to compliance reporting programs

Qualifications:

Required Skills and Abilities:

• 5 years of experience in health care compliance, with specific exposure to self-funded and/or level-funded group health plans in a TPA environment

• Demonstrated, hands-on expertise with CMS Section 111 reporting, RxDC D2/P2 reporting, Gag Clause Attestation, TiC/MRF compliance, PCORI filings, and NSA/IDR processes

• Strong understanding of ERISA, ACA, HIPAA, and the Consolidated Appropriations Act (CAA) as they apply to self-insured health plans

• Experience drafting or reviewing SPDs and SBCs in compliance with DOL and ACA requirements

• Proven ability to manage multiple concurrent regulatory deadlines with a high degree of accuracy and accountability

• Excellent written and verbal communication skills; able to translate complex regulatory requirements into clear guidance for clients and non-compliance audiences

• Proficiency with Microsoft Office Suite; experience with claims systems and compliance tracking tools

• Regulatory Acumen – Maintains current, working knowledge of federal health care regulations and applies them operationally

Preferred Qualifications:

• Bachelor's degree in Health Care Administration, Business, Paralegal Studies, or a related field; advanced degree or relevant certifications (CEBS, CHC, CSFS) a plus

• Familiarity with stop-loss insurance structures and their interaction with self-funded compliance obligations

• Experience working directly with CMS COBSTP/BCRC systems for Section 111 submissions

• Experience working Javelina, Health Rules Payor and/or Ringmaster platforms

• Prior experience presenting compliance topics to employer plan sponsors, brokers, or advisory committees

Work Location:

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

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.

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.