Healthcare Claims Operations Manager

Job 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. • Represent UST HealthProof at client Change Approval Boards for ingestion readiness, risks, and approvals.

• Provide operational metrics, trend analysis, and SLA reporting to leadership and customers. • 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 communication skills and the ability to interact effectively with peers, vendors, customers, and leadership. • Strong planning, coordination, and documentation skills. Benefits: • HealthEdge commits to building an environment and culture that supports the diverse representation of our teams.

• We aspire to have an inclusive workplace. We aspire to be a place where all employees have the opportunity to belong, make an impact and deliver excellent software and services to our customers. Apply tot his job

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