Director of Health Plan Administration

Company: Covet Health

Location: New York, NY / Hybrid

Reports to: Chief Operating Officer

About Covet Health

Covet Health is a modern, API-first TPA and benefits provider. We leverage technology and data-driven care pathways to improve healthcare delivery for employers and members. We prioritize transparency and precision in claims administration. We are seeking a leader who values operational excellence and innovation to join our growing team.

The Role

We are looking for a Director of Health Plan Administration to serve as the strategic lead for our claims department. You will be responsible for overseeing the full claims lifecycle, ensuring accuracy, managing stop-loss reimbursements, and utilizing data to optimize plan performance. You will lead an established team, providing the high-level oversight required for complex claims audits and operational scalability.

Key Responsibilities

Operational Leadership

• Team Management: Mentor and develop a team of department managers, claims examiners, and auditors. Oversee hiring, performance management, and quality control.
• Quality & Compliance: Implement rigorous auditing standards to maintain industry-leading claims benchmarks and ensure full HIPAA and ERISA compliance.
• Lifecycle Management: Oversee the technical claims process, from EDI 837 intake and clearinghouse scrubbing to adjudication and final EOB generation.
• Repricing Optimization: Manage integration between the claims engine and external repricing vendors to ensure consistent application of PPO and Reference-Based Pricing (RBP).
• Process Improvement: Identify and resolve systemic bottlenecks within the claims lifecycle to improve turnaround times.

Data Analytics & Reporting

• Advanced Reporting: Develop sophisticated reporting models for executive leadership and clients, focusing on turnaround times, cost-containment, and performance metrics.
• Quality Governance: Standardize review processes for high-dollar, pended, and outlier claims.
• Process Automation: Identify manual workflows and implement automated, system-driven solutions to enhance departmental efficiency.

Stop Loss Strategy

• Reimbursement Management: Oversee the lifecycle of Specific and Aggregate Stop Loss claims, ensuring timely filings and maximizing client reimbursements.
• Policy & Compliance: Act as the subject matter expert on Stop Loss policy provisions, ensuring alignment between Summary Plan Descriptions (SPD) and carrier contracts.
• Carrier Relations: Maintain relationships with Stop Loss carriers and brokers to resolve claim disputes.

Subrogation & Cost Recovery

• Recovery Protocols: Establish and enforce protocols for identifying third-party liability (TPL) and subrogation cases.
• Workflow Oversight: Manage the end-to-end subrogation process, including member notification and coordination with external recovery vendors.

Qualifications

• Experience: 7+ years in health claims administration, with at least 3 years in a leadership or management capacity.
• Education: Bachelor’s degree in Business, Finance, Healthcare Administration, or a related field.
• Technical Expertise: Advanced proficiency in Microsoft Excel (VLOOKUP/XLOOKUP, Pivot Tables, Power Query). Experience with modern EHR/TPA platforms (e.g., Healthie) is preferred.
• Subject Matter Knowledge: Strong understanding of self-funded plan mechanics, PPO network structures, and alternative reimbursement models.

Covet Health is an equal opportunity employer. We celebrate diversity and are committed to creating an inclusive environment for all employees.