Job Overview
Location
USA
Job Type
Full-time
Category
HR & Recruiting
Date Posted
March 18, 2026
Full Job Description
đź“‹ Description
- • The Claims Compliance Manager at Centivo Inc. serves as the organization's subject matter expert on regulatory compliance for self-funded and level-funded health plan products, ensuring timely and accurate fulfillment of all mandated reporting obligations to clients, plan sponsors, and federal regulatory bodies including CMS, DOL, IRS, and HHS.
- • This role is critical to maintaining Centivo’s mission of delivering affordable, high-quality healthcare by safeguarding compliance integrity across complex federal healthcare laws, directly supporting employer clients in avoiding penalties and ensuring plan validity.
- • Day-to-day responsibilities include owning and executing CMS Section 111 (MSP) reporting, managing RxDC reporting under the CAA, preparing PCORI fee filings via IRS Form 720, and maintaining a compliance calendar to track deadlines and communicate status to stakeholders.
- • The role involves administering Gag Clause Prohibition Attestations, leading Transparency in Coverage (TiC) compliance efforts including machine-readable file (MRF) production, and supporting Preferred Networks disclosures and SPD/SBC document reviews to ensure alignment with regulatory standards.
- • The manager serves as the internal SME on No Surprises Act (NSA) compliance, managing Good Faith Estimate (GFE) requirements, Explanation of Benefits (EOB) standards, and coordinating NSA negotiations and Independent Dispute Resolution (IDR) proceedings for out-of-network claims.
- • A key function includes contributing to the Fraud, Waste & Abuse (FWA) program by monitoring claims data for anomalies, flagging suspect claims, liaising with law enforcement agencies like the FBI and OIG, and preparing referral documentation when external action is warranted.
- • The role requires collaboration with Special Investigations Unit (SIU) resources, external auditors, and stop-loss carriers on investigations, while educating internal teams and clients on common FWA schemes such as upcoding, unbundling, and phantom billing.
- • As a client-facing expert, the manager develops and delivers compliance guides, reporting summaries, and educational materials, distributes required filings to clients and partners, and translates evolving regulatory guidance into actionable procedures.
- • Internal operations duties involve building, documenting, and improving workflows and SOPs, collaborating with Claims, IT, Account Management, Legal, and Finance teams to ensure data integrity, and proactively identifying and escalating compliance risks with corrective action plans.
- • The position supports audit requests and regulatory examinations, requiring strong organizational skills to manage multiple concurrent deadlines with precision and accountability.
- • Centivo’s culture emphasizes resilience, uncommon innovation, and positivity — values that drive the team to solve complex healthcare affordability challenges through collaboration, humility, and a member- and employer-first mindset.
🎯 Requirements
- • 5 years of experience in health care compliance with specific exposure to self-funded and/or level-funded group health plans in a Third Party Administrator (TPA) environment
- • Demonstrated hands-on expertise with CMS Section 111 reporting, RxDC D2/P2 reporting, Gag Clause Attestation, TiC/MRF compliance, PCORI filings, and NSA/IDR processes
- • Strong understanding of ERISA, ACA, HIPAA, and the Consolidated Appropriations Act (CAA) as they apply to self-insured health plans
- • Experience drafting or reviewing Summary Plan Descriptions (SPDs) and Summaries of Benefits and Coverage (SBCs) in compliance with DOL and ACA requirements
- • Proven ability to manage multiple concurrent regulatory deadlines with a high degree of accuracy and accountability
- • Excellent written and verbal communication skills; ability to translate complex regulatory requirements into clear guidance for clients and non-technical audiences
- • Proficiency with Microsoft Office Suite and experience with claims systems and compliance tracking tools
🏖️ Benefits
- • Remote work flexibility with option to work onsite in Buffalo, NY office
- • Opportunity to work on mission-driven healthcare innovation that saves employers 15–30% vs. traditional carriers and provides employees with free primary care and predictable copays
- • Backed by leading investors including Morgan Health (JPMorgan Chase & Co.), offering stability and growth potential in a rapidly expanding health tech company
- • Exposure to cutting-edge compliance challenges across federal healthcare regulations, enabling deep expertise in NSA, TiC, RxDC, and FWA domains
- • Collaborative, values-driven culture emphasizing resilience, positivity, and uncommon thinking — where employees are supported, recognized, and energized by shared purpose
- • Professional development through interaction with legal, claims, IT, and finance teams, plus opportunities to present compliance topics to employers, brokers, and advisory committees
Skills & Technologies
Go
Remote
Degree Required
About Centivo Inc.
Centivo is a health plan administrator that partners with self-insured employers to provide affordable healthcare benefits. It builds custom networks of high-value primary care providers and specialists, emphasizing coordinated care, transparent pricing, and payment innovations like prospective bundled payments. The platform offers members digital tools for provider search, cost estimates, and care navigation, while giving employers predictable costs and data analytics to improve population health outcomes.
