Claims Manager - Management Ancillary Support (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:

Centivo is seeking a Manager, Claims – Management Ancillary Support (CMAS) to lead the teams responsible for claims audit, appeals, escalations, recoveries, subrogation, NSA, and quality oversight.

This role is accountable for operational results across CMAS functions, including accuracy, compliance, inventory management, and turnaround times. The Manager directly leads the CMAS team while partnering cross-functionally to resolve dependencies, standardize processes, and improve execution across claims workflows.

Responsibilities Include:

· Ensure claims, appeals, and adjustments are processed accurately and in accordance with benefit plans, pricing agreements, authorizations, and regulatory requirements, intervening as needed to resolve issues and escalations.

· Oversee and manage claim inventory against established service-level agreements (SLAs), setting priorities for team members.

· Direct, coach, and develop staff, ensuring proper application of client benefit plans and achievement of quality and production standards; establish and monitor performance plans for team members falling below expectations.

· Establish clear accountability for training and onboarding outcomes, ensuring skill development is treated as essential to core operations.

· Lead the development and refinement of operational and quality KPIs across CMAS functions, with particular focus on day-to-day performance, appeals timeliness, and regulatory compliance.

· Review, analyze, and report on operational performance, including claim inventory, production volumes, turnaround lag, and quality metrics, and communicate trends and risks to department leadership.

· Develop and execute work plans to reduce claim inventory and improve service performance, including oversight of overtime usage to ensure cost effectiveness.

· Identify and drive process improvement opportunities, including workflow standardization, automation, and AI-enabled enhancements, to improve efficiency, quality, and turnaround times.

· Oversee the development and enforcement of policies and procedures to ensure claim standards are administered consistently; monitor team compliance and address gaps.

· Set team goals aligned with departmental and organizational priorities, providing ongoing feedback and formal performance evaluations to support individual growth and accountability.

· Maintain accountability for team morale and engagement, fostering collaboration by involving staff in problem-solving and solution design.

· Serve as the CMAS liaison on projects and initiatives, including claims testing and support for system implementations or upgrades.

· Partner cross-functionally to support client issue resolution and implementation efforts, ensuring CMAS considerations are incorporated into broader claims workflows.

· Act as a point of contact as needed for clients, vendors, or providers requiring CMAS relationship ownership.

· Perform other duties as deemed essential and necessary.

Qualifications:

Required:

· Bachelor’s degree or equivalent work experience required.

· 5+ years of experience in healthcare claims administration; self-funded and/or TPA experience strongly preferred.

· Demonstrated experience managing teams involved in claims audit, appeals, recovery, quality, or escalations.

· Strong understanding of benefit administration, claims adjudication, and regulatory requirements.

· Experience managing operational metrics, quality programs, and service levels in a regulated environment.

· Prior experience with highly automated and integrated claims adjudication systems (e.g., Javelina, Health Rules Payer, or similar).

· Strong communication, organizational, analytical, and problem-solving skills.

· Proficiency in Microsoft Word, Excel, Outlook, and PowerPoint.

Preferred Qualifications:

· Direct ownership of a quality assurance or audit program.

· Experience with member appeals, recoveries, subrogation, NSA, overpayments, and complex escalations.

· Experience improving KPIs and workflows during periods of operational change.

· Ability to conduct structured root-cause analysis and translate findings into practical improvements.

Work Location:

· The strong preference is for a candidate that is local to WNY, with the ability and expectation of working from the Buffalo office, coupled with the ability to also work from home

· If a strong WNY-based candidate is not available, remote candidates may be considered.

Leadership Skills:

· Business Acumen – A keenness and quickness in understanding and dealing with a business situation (risks and opportunities) in a manner that is likely to lead to a good outcome. Critical to this is an ability to think beyond their own function.

· Accountability & Execution – Taking ownership of actions, following through on commitments, actively carrying out tasks, monitoring progress, delivering results as promised, and being answerable for positive and negative outcomes.

· Strategist Mindset - The ability see and articulate the bigger picture, thinking proactively and anticipating both opportunities and obstacles in the context of setting direction and maintain alignment to long-term company goals.

· Systems Thinking – The ability to see and articulate the patterns, interconnections and interdependencies within a system

· Process Orientation – The ability to see and articulate the sequential flow of activities, including anticipating impacts upstream and downstream when processes are changed.

· Flexibility/Working through Ambiguity – Tendency to be energized by new experiences/perspectives, working with both data and fragmented information to arrive at practical, effective, actionable next steps

Leadership Behaviors:

· Communicate – Managers discuss the company’s vision and strategies, the department’s direction and goals, and in times of crisis, what we know and don’t know to make sure team members know what they need to know.

· Clarify – As managers, it’s up to us to clarify what good looks like. What do we expect? What do our clients, customers or colleagues need? If our teams are not performing as expected, managers must clarify expectations and ensure understanding.

· Coach – Managers provide recognition and feedback; help team members find solutions to challenges; amplify good and filter weaker aspects of organizational culture and the work as they coach employees in their day-to-day performance and their growth and career development.

· Connect – Managers help our teams see their collective purpose and how their work connects to the greater whole. We connect people within our company and network.

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.