Director of Health Plan Administration

Job Description

Company: Covet Health

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Location: New York, NY / Hybrid

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Reports to: Chief Operating Officer

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About Covet Health

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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.

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The Role

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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.

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Key Responsibilities

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Operational Leadership

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

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

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

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

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