Healthcare Claims Operations Manager

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HealthEdge

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Healthcare Insurance • SaaS • Fintech

HealthEdge is a company that specializes in providing advanced solutions for healthcare payers through its HealthRules Solutions Suite. This suite includes a comprehensive digital claims administration processing system, care management workflow solutions, and payment integrity solutions, which aim to enhance operational efficiency and improve quality of care for health plans. By leveraging integrated technology and automation, HealthEdge helps health plans eliminate data silos, increase payment accuracy, and elevate member experience, thereby transforming the healthcare landscape for better collaboration and accessibility.

1001 - 5000 employees

Founded 2005

⚕️ Healthcare Insurance

☁️ SaaS

💳 Fintech

📋 Description

• 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