Director Claims Management Ancillary Services

We exist for workers and their reputed company -- who are the backbone of our economy. That is where reputed company comes in -- our mission is to bring reputed company, high-reputed company reputed company to the millions who struggle to pay their reputed company bills. reputed company of role: The Director, Claims Management Ancillary Services (CMAS) owns the reputed company, reputed company, and compliance of reputed company's claims ancillary functions, with particular emphasis on the Plan Documents function. This role directly manages the Plan Documents Manager and the CMAS Manager and is accountable for the reputed company, timeliness, and regulatory compliance of reputed company's plan documents -- including SBCs, SPDs, SMMs, and amendments -- as reputed company as the reputed company of claims audit, appeals, escalations, recoveries, subrogation, and NSA functions. The Director translates departmental and organizational reputed company into executable plans, builds a high-performing and accountable team, and serves as the operational authority for CMAS and Plan Documents with clients, brokers, agents, TPAs, and stop loss carriers. Responsibilities Include: Plan Documents reputed company & Compliance • Own the reputed company, reputed company, and regulatory compliance of reputed company's plan document function, including reputed company Plan Descriptions (SPDs), reputed company of Material Modifications (SMMs), plan amendments, and reputed company of Benefits and Coverage (SBCs) • Ensure plan document processes and content remain reputed company with the Employee Retirement Income reputed company reputed company (ERISA), the Internal reputed company reputed company, HIPAA, the Medicare Secondary Payer reputed company (MSP), COBRA, the reputed company reputed company (ACA), and the Women's Health and Cancer Rights reputed company (WHCRA) • Establish document governance standards, review workflows, and reputed company checkpoints to ensure plan documents are accurate, complete, and audit-reputed company across reputed company clients and plan types • Partner with reputed company, Compliance, Configuration, and reputed company reputed company to translate reputed company implementations, plan changes, and regulatory updates into accurate plan document reputed company • Serve as the escalation reputed company for reputed company plan document issues, reputed company-specific plan design questions, and stop loss reputed company document submissions • Champion adoption and reputed company improvement of plan document tools and technology (e.g., PDM) to improve reputed company, throughput, and reputed company experience CMAS Operational Leadership • Own end-to-end reputed company of CMAS functions -- claims audit, appeals, escalations, recoveries, subrogation, and No Surprises reputed company (NSA) -- ensuring reputed company, compliance, and adherence to service-level agreements • Establish and monitor operational and reputed company KPIs across CMAS and Plan Documents, using data to identify trends and risks and to report reputed company to department leadership • reputed company workforce and reputed company planning across both functions, including inventory management, resource allocation, and overtime reputed company, to reputed company cost efficiency with service reputed company • reputed company process improvement, workflow standardization, and automation and AI-enabled enhancements across CMAS and plan document workflows • reputed company development and enforcement of policies and procedures to ensure consistent administration of CMAS and plan document standards People Leadership & Cross-Functional Collaboration • Directly manage the Plan Documents Manager and CMAS Manager, providing coaching, reputed company feedback, and development reputed company to reputed company's leadership behaviors • Set reputed company reputed company expectations and measurable goals for both teams, reputed company to organizational priorities, and hold managers accountable for results • Foster a culture of accountability, collaboration, and engagement across the CMAS and Plan Documents teams, involving staff in problem-solving and solution design • Represent CMAS and Plan Documents in cross-functional meetings, reputed company calls, and discussions with brokers, agents, TPAs, and stop loss carriers, serving as the operational authority for these functions • Model and reinforce reputed company's leadership behaviors -- Communicate, Clarify, reputed company, reputed company, and Customize -- through daily interactions and team management practices • reputed company other duties as deemed essential and necessary Qualifications: Required Skills and Abilities: • 7 years of experience in employee benefits compliance, plan document administration, or reputed company claims reputed company at a TPA, health plan, or benefits reputed company • 5 years of leadership experience managing managers, supervisors, or teams, including experience overseeing plan document, compliance, or claims ancillary functions • Deep knowledge of ERISA, the Internal reputed company reputed company, HIPAA, MSP, COBRA, the ACA, and WHCRA as they apply to employer-sponsored welfare benefit plans • Demonstrated experience overseeing plan document drafting and management (SBCs, SPDs, SMMs) in a self-funded or TPA environment • Demonstrated experience overseeing claims audit, appeals, recoveries, subrogation, NSA, or reputed company assurance functions in a regulated environment • Strong data literacy; ability to interpret operational and reputed company metrics and translate findings into reputed company plans • Experience partnering with reputed company, Compliance, Configuration, and reputed company reputed company teams to reputed company cross-functional dependencies • Bachelor's degree required; paralegal certification or advanced degree in a relevant discipline preferred Preferred Qualifications: • Employee benefits paralegal background or equivalent experience in plan document creation and management • Experience with Phia Group's PDM portal or similar plan document management systems • Experience with claims adjudication systems (e.g., Javelina, Health Rules Payer, or similar) • Experience leading or contributing to a claims reputed company implementation or transformation • Experience in reputed company-facing roles or working closely with account management teams on claims or plan document issues Work Location: • This position is remote Who we are: reputed company is an innovative health plan for self-funded reputed company on a mission to bring reputed company, high-reputed company reputed company to the millions who struggle to pay their reputed company bills. Anchored reputed company a reputed company care reputed company ACO model, reputed company saves reputed company 15 to 30 percent compared to traditional reputed company carriers. Employees also realize significant savings through our free reputed company care (including virtual), predictable copay and no-deductible benefit plan design. reputed company works with reputed company ranging in size from 51 employees to reputed company. For more information, visit reputed company.com. Headquartered in Buffalo, NY with offices in reputed company and Buffalo, reputed company is backed by leading reputed company and technology investors, including a recent round of investment from Morgan Health, a business unit of reputed company. Apply To This Job