Senior Manager, Claims Systems
Collective Health · San Francisco, CA | Lehi, UT | Plano, TX
About this role
**Collective Health — Senior Manager, Claims Systems** ## About the Role Collective Health is transforming how employers and their people engage with health benefits by combining cutting-edge technology, compassionate service, and world-class user experience design. We’re seeking an experienced **Senior Manager, Claims Systems** to lead specialized teams responsible for **Accumulator Operations**, **EDI 837 Ingestion & File Resolution**, and **Claims Performance & Resolution (CPR)**. ## Key Responsibilities ### Claims Systems & Technical Oversight - **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. ### Cross-Functional Partnership & Operational Excellence - 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. ### People Leadership & Accountability - 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. ## Skills & Qualifications ### Minimum Qualifications - **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). - Strong technical understanding of **EDI 837 transactions**, clearinghouse exchanges, file ingestion, system coding/logic, and error resolution. - Demonstrated expertise in **end-to-end claims adjudication** workflows, benefit hierarchy, health plan configuration, pend rules, and identifying systemic processing gaps. - Experience with **accumulator reconciliation**, cro
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