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About the Role

Collective Health is 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). 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.

Responsibilities

Oversee institutional and professional claims transactions (837I/837P), investigate ingestion rejections, resolve return file errors, and maintain data integrity across claims processing workflows.
Lead accumulator research, reconciliation, transfers, and over-accumulation remediation across medical and pharmacy benefit integrations.
Oversee system defect triage, Run-The-Business (RTB) gap identification, and adjudication pend rule configuration and maintenance.
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.
Independently investigate complex claims processing failures, distinguish between operational, configuration, EDI, and system defects, and drive appropriate resolution.
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.
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.

Requirements

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 and logic, and error resolution.
Demonstrated expertise in claims adjudication workflows, benefit hierarchy, health plan configuration, pend rules, and identifying systemic processing gaps.
Experience with accumulator reconciliation, cross-benefit transfers, over-accumulation research, and synchronization.
Ability to independently diagnose complex system defects, identify root causes, and translate findings into actionable solutions for Product and Engineering.
Experience partnering with technical and operational stakeholders to prioritize system improvements, resolve defects, and reduce manual processing.
Proven ability to develop technical teams, delegate responsibilities, establish accountability, make difficult decisions, and lead through organizational change.

Skills

EDI 837 transactions
Clearinghouse exchanges
File ingestion
System coding and logic
Error resolution
Claims adjudication workflows
Benefit hierarchy
Health plan configuration
Pend rules
Systemic processing gaps
Accumulator reconciliation
Cross-benefit transfers
Over-accumulation research
Synchronization
Technical problem-solving
Cross-functional collaboration
People leadership

Location

San Francisco, CA
Lehi, UT
Plano, TX

Work Type

Hybrid

Experience Level

Senior Manager
10+ years of experience

Salary/Compensations

San Francisco, CA Pay Range $137,500—$171,875 USD
Lehi, UT Pay Range $110,000—$137,500 USD
Plano, TX Pay Range $121,000—$151,250 USD

Benefits

135,000 stock options
Health insurance
401k
Paid time off

About the Company

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.
Mission-driven culture that values innovation, collaboration, and a commitment to excellence in healthcare
Impactful projects that shape the future of our organization
Opportunities for professional development through internal mobility opportunities, mentorship programs, and courses tailored to your interests
Flexible work arrangements and a supportive work-life balance

Equal Opportunity

We are an equal opportunity employer and value diversity at our company. We do not discriminate on the basis of race, religion, color, national origin, gender, sexual orientation, age, marital status, veteran status, or disability status. Collective Health is committed to providing support to candidates who require reasonable accommodation during the interview process. If you need assistance, please contact recruiting-accommodations@collectivehealth.com.