Senior Director, Network and File Operations

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Luminare Health

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1001 - 5000 Mitarbeiter

⚕️ Krankenversicherung

Healthcare Insurance

Luminare Health ist ein führender Anbieter von Verwaltungsdienstleistungen für selbstfinanzierte Gesundheitspläne mit über 50 Jahren Branchenerfahrung. Das Unternehmen spezialisiert sich auf flexible und innovative Lösungen für Krankenhäuser, Gesundheitssysteme und direkte Arbeitgeberinitiativen, mit einem Schwerpunkt auf Verwaltung, Kostenmanagement und digitalen Berichterstattungstools. Luminare Health widmet sich der Rolle eines verlässlichen Partners für das Management von Gesundheitskosten und unterstützt das strategische Wachstum seiner Kunden. Das Unternehmen legt Wert auf einen mitgliedszentrierten Ansatz im Gesundheitswesen, während es durch Expertenanalysen von Ansprüchen und das Management von kostenintensiven Ansprüchen erhebliche Einsparungen liefert.

Beschreibung

• 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.

🎯 Anforderungen

• 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.

🏖️ Vorteile

• 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