Senior Manager, Claims Systems

At Collective Health, we’re transforming how employers and their people engage with their health benefits by seamlessly integrating cutting-edge technology, compassionate service, and world-class user experience design.

Collective Health is reimagining health benefits through technology-driven, member-focused healthcare administration. We are seeking an experienced Senior Manager, Claims Systems to lead the specialized teams responsible for Accumulator Operations, EDI 837 Ingestion & File Resolution, and Claims Performance & Resolution (CPR).

This role requires deep technical knowledge of end-to-end claims adjudication, EDI transactions, benefit hierarchy, health plan configuration, and claims system logic. The ideal candidate can independently identify systemic gaps, translate complex operational issues into actionable technical requirements, and partner with Product and Engineering to drive sustainable solutions.

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.

- EDI & Claims Systems Expertise: Strong technical understanding of EDI 837 transactions, clearinghouse exchanges, file ingestion, system coding and logic, and error resolution.

- End-to-End Adjudication Knowledge: Demonstrated expertise in claims adjudication workflows, benefit hierarchy, health plan configuration, pend rules, and identifying systemic processing gaps.

- Accumulator Operations: Experience with accumulator reconciliati