Healthcare Claims Operations Manager
HealthEdge
full-time
Posted on:
Location Type: Remote
Location: Remote • 🇺🇸 United States
Visit company websiteSalary
💰 $110,000 - $130,000 per year
Job Level
Mid-LevelSenior
Tech Stack
AWSCloudETLGoogle Cloud PlatformServiceNowSOAPSQL
About the role
- Build, lead, and mentor a Claims Ingestion Center of Excellence responsible for enterprise-wide claims intake.
- Define staffing plans and oversee hiring, onboarding, and capability development.
- Establish performance standards, operational KPIs, and quality benchmarks for the COE.
- Serve as the enterprise SME for claims ingestion, including SNIP edits, validation logic, provider/EDI rules, and common transaction defects.
- Oversee daily ingestion operations ensuring all claims are successfully received, validated, and loaded into the claims systems.
- Lead complex troubleshooting across ingestion pipelines, EDI gateway issues, companion guide variances, and partner/vendor data errors.
- Ensure consistent application of business rules, system edits, and SNIP level requirements.
- Develop and implement standardized ingestion processes, templates, SOPs, and best-practice frameworks across all clients.
- Define and enforce enterprise ingestion SLAs and quality controls.
- Monitor ingestion trends to identify systemic issues, gaps, and improvement opportunities.
- Drive resolution and root cause analysis for ingestion incidents, defects, and load failures.
- Oversee the management of ingestion-related tickets in Jira/ServiceNow, ensuring accuracy, prioritization, and timely triage.
- Partner with vendors, EDI trading partners, and upstream/downstream system owners to resolve ingestion, translation, or formatting issues.
- Participate in internal Change Approval Boards for ingestion-impacting changes.
- Lead customer calls focused on ingestion performance, issue status, and optimization opportunities.
Requirements
- Bachelor’s degree in a business or technical field, or equivalent experience.
- 6+ years of experience managing a mid- to large-scale production support or operations environment.
- Deep experience with healthcare payer claims, including SNIP levels, EDI validation, and claims intake workflows.
- Strong expertise with EDI transactions, particularly 837, 270/271, 276/277, and 835.
- Experience working with healthcare payer platforms such as Facets, QNXT, NASCO, or similar.
- Strong knowledge of service management tools such as Jira Service Management and ServiceNow.
- Strong experience supporting high-governance and compliance-controlled environments.
- Ability to manage Sev1/Sev2 ingestion incidents with confidence and urgency.
- Experience with SQL required; experience with ETL, SOAP, cloud platforms (AWS/GCP), and HealthEdge applications is a plus.
- ITIL knowledge or certification preferred.
- Proven experience leading teams, driving process improvement, and establishing operational best practices.
- Experience working in an onshore/offshore delivery model.
- Strong planning, coordination, and documentation skills.
Benefits
- Health insurance
- 401(k) matching
- Paid time off
- Remote work options
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard skills
claims ingestionSNIP editsvalidation logicEDI rulesEDI transactions837270/271276/277835SQL
Soft skills
leadershipmentoringproblem-solvingprocess improvementplanningcoordinationdocumentationcommunicationcustomer engagementroot cause analysis
Certifications
ITIL