Senior Director, Network and File Operations

🕒 May 11

Apply Now

Find Similar Remote Jobs

Receive Emails For Remote Jobs

📊 Check your resume score for this job

Improve your chances of getting an interview by checking your resume score before you apply.

Upload Resume

Luminare Health

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

⚕️ Healthcare Insurance

Healthcare Insurance

Luminare Health is a leading provider of self-funded health plan administration services with over 50 years of industry experience. The company specializes in offering flexible and innovative solutions for hospitals, health systems, and direct-to-employer initiatives, focusing on administration, cost management, and digital reporting tools. Luminare Health is dedicated to being a reliable partner in managing healthcare costs and supporting strategic growth for its clients. The company emphasizes a member-centered approach to healthcare while delivering significant savings through expert claim analysis and management of high-cost claims.

📋 Description

• Network Integration and provider maintenance leadership • Direct the end-to-end integration of hospital, physician, ancillary, and specialty networks into enterprise systems. • Ensure accurate and timely processing of provider demographics, contracts, fee schedules, reimbursement methodologies, participating status, and network tiering. • Partner with the EDI and Network operations teams to ensure data file flows and standards are maintained; failure points are identified and improved, and automated monitoring alerts are reviewed and resolved quickly. • Develop and maintain standardized workflows for network onboarding, mapping, quality assurance, and validation. • Partner with operational units and client managers to ensure that client needs are clearly understood, and setups are executed to support those needs. • Partner with hospital system clients to develop scalable, sustainable processes • Provide leadership for the modernization, standardization, and governance of provider network integration, ensuring alignment with long-term corporate and operational strategy. • Establish and oversee frameworks for accuracy, quality, automation, and compliance in all provider and file integration activities. • Shape and drive multi-year roadmaps for digital transformation and integration scalability, guiding cross-functional teams • Lead high-performing teams through a culture of innovation, accountability, and continuous improvement that supports enterprise performance objectives. • Overall accountability for setting, communicating and delivering on team and individual goals that are aligned with company and client interests. • Handle personnel matters including mentoring, coaching, motivating, performance management and feedback, recognition, performance evaluation and time tracking of direct reports. • Responsible for staff decisions; onboard, offboard, promote. • Provide input into compensation and promotional increases. • Regularly communicate with staff via management meetings and one-on-one meetings with team members. • Mentor and develop leaders within team. • Interview and recommend viable candidates for job openings. • Oversee outbound file integration teams to ensure successful implementation of files to new and existing point solution vendors • Ensure organization is adhering to all data sharing and security protocols when sending data to outside vendors • Overall accountability for maintaining relationships with key vendors and partners • Responsibility for collaborating with IT to manage and troubleshoot day to day file integration issues • Metric tracking and adherence to applicable outbound file KPIs and client SLAs, including, but not limited to file quality and delivery schedule. • Oversee the execution, maintenance, and adherence to outbound file-related process documentation, ensuring that all material is digestible and comprehensive. • Own the lifecycle of file integrations, including requirements gathering, file layout design, mapping, validation rules, scheduling, and monitoring. • Establish SLAs for file delivery, error resolution, and quality control. • Evaluate new technologies, automation tools, and integration platforms to enhance operational performance.

🎯 Requirements

• Bachelor’s Degree and 12 years of related business experience in TPA/Payer operations • 5 years leadership experience • Ability to develop business strategy and convert into action-oriented objectives and measurable results in partnership with product, other operational and IT partners. • Broad understanding of and experience in the health care/insurance industry. • Advanced degree/education preferred. • Experience applying Lean process methodologies to improve operational efficiency. • Experience with network integration, provider maintenance, outbound file integration • Understanding of healthcare data interchange formats, including X12 EDI transactions (834, 835, 837, 820, 270/271, 276/277, 999, and related companion guides). • Ability to interpret vendor file specs and guide teams through mapping, validation, balancing, and certification processes.

🏖️ Benefits

• health and wellness benefits • 401(k) savings plan • pension plan • paid time off • paid parental leave • disability insurance • supplemental life insurance • employee assistance program • paid holidays • tuition reimbursement • other incentives