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.
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