Senior Director, Network and File Operations

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🔥 0 minutes ago

🇺🇸 United States – Remote

💵 $102.9k - $193.2k / year

⏰ Full Time

🟠 Senior

⚙️ Operations

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Health Care Service Corporation

WebsiteLinkedInAll Job Openings

10,000+ employees

🛡️ Insurance

💼 Consulting

🏥 Healthcare

Insurance • Consulting • Healthcare

Health Care Service Corporation is an independent licensee of the Blue Cross Blue Shield Association, serving nearly 23 million people across the United States with a wide range of health benefit solutions. The company provides health coverage options for various groups, including employers, individuals, families, as well as Medicare and Medicaid plans. In addition to health insurance, HCSC offers services such as pharmacy solutions, life and dental insurance, and health data technology. With nearly a century of experience, HCSC is dedicated to improving access to quality care, enhancing health outcomes, and reducing costs while maintaining a deep commitment to its members and local communities.

📋 Description

• Direct 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 EDI and Network Operations teams to maintain data file flows and standards, identify failure points, and resolve monitoring alerts • Develop standardized workflows for network onboarding, mapping, quality assurance, and validation • Partner with operational units, client managers, and hospital system clients to deliver scalable network processes • Lead modernization, standardization, governance, automation, quality, and compliance of provider and file integration • Shape multi-year digital transformation and integration scalability roadmaps • Lead high-performing teams and establish, communicate, and deliver team and individual goals • Mentor, coach, motivate, evaluate, and manage direct reports • Make staff decisions, including onboarding, offboarding, promotions, and candidate recommendations • Oversee outbound file integration teams implementing files for point-solution vendors • Ensure adherence to data-sharing and security protocols • Maintain relationships with key vendors and partners • Collaborate with IT to manage and troubleshoot day-to-day file integration issues • Track metrics and ensure adherence to outbound-file KPIs and client SLAs • Oversee outbound file process documentation • Own file-integration lifecycles, including requirements gathering, file layout design, mapping, validation, scheduling, and monitoring • Establish SLAs for delivery, error resolution, and quality control • Evaluate technologies, automation tools, and integration platforms to improve operational performance

🎯 Requirements

• Bachelor’s Degree and 12 years of related business experience in TPA/Payer operations • 5 years of leadership experience • Ability to develop business strategy and convert it into action-oriented objectives and measurable results with product, operational, and IT partners • Broad understanding of and experience in the health care/insurance industry • Experience applying Lean process methodologies to improve operational efficiency • Experience with network integration, provider maintenance, and outbound file integration • Hands-on experience supporting business operations leveraging the HealthEdge platform, including claims administration, provider configuration, network management, enrollment, benefits, payment integrity, and related operational workflows • Proven success partnering with business stakeholders to optimize HealthEdge-enabled processes, drive operational efficiency, and improve service delivery • 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 specifications and guide teams through mapping, validation, balancing, and certification processes • Remote employees must live within the continental United States, excluding Alaska, California, Hawaii or New York • Sponsorship is not available

🏖️ Benefits

• Thoughtful development opportunities • 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 • Annual incentive bonus plan • Remote/telecommute work arrangement