Healthcare Claims Technical Operations Manager

PowerToFly; Remote; EUR 93.000 - 111.000; Vollzeit

Zusammenfassung

A healthcare technology company is seeking a COE Manager for its Claims Ingestion operations. The role involves leading a dedicated team and ensuring high-quality claims intake across clients. Responsibilities include overseeing ingestion operations, developing standardized processes, and driving continuous improvement. Candidates should have a bachelor's degree, significant experience in claims with healthcare payers, and strong communication skills. This is a full-time remote position with a salary range of $110k-$130k.

Qualifikationen

• 6+ years of experience managing a mid- to large-scale production support or operations environment.
• Deep experience with healthcare payer claims, including SNIP levels and EDI validation.
• Strong knowledge of service management tools.

Aufgaben

• Build and lead a Claims Ingestion Center of Excellence responsible for enterprise-wide claims intake.
• Develop and implement standardized ingestion processes and best practices.
• Drive resolution and root cause analysis for ingestion incidents.

Kenntnisse

Claims ingestion expertise

Team leadership

Troubleshooting

Communication skills

Process improvement

Ausbildung

Bachelor’s degree in a business or technical field

Tools

Jira Service Management

ServiceNow

SQL

Jobbeschreibung

Overview

About HealthEdge. HealthEdge® is trusted to provide the technology and services that power health plans’ most important value streams. With an integrated platform of solutions spanning claims administration, quality improvement, prospective payment accuracy, provider network management, care management, member engagement and risk adjustment, HealthEdge enables health plans to converge their data so they can harness automation and the promise of AI. Combining this next‑gen technology with services and expertise gives health plans unmatched capabilities to deliver a future of frictionless and cost‑effective healthcare experiences. For more information, visit www.HealthEdge.com.

Position Overview

We are searching for a highly skilled and experienced COE Manager to join our growing team. The Manager, Claims Ingestion Center of Excellence (COE), will be instrumental in planning, coordinating, and optimizing all claims ingestion operations across UST HealthProof’s customer‑facing delivery ecosystem. Guided by UST HealthProof’s values, this role will build, lead, and scale a dedicated team responsible for ensuring accurate, timely, and high‑quality claims intake across all clients and implementations.

This leader will establish best practices, implement standardized processes, and drive continuous improvement across enterprise ingestion workflows. The Manager will also serve as an enterprise expert in claims edits, SNIP validation levels, and automated and manual troubleshooting, ensuring that all claims are properly received, validated, and loaded into the core claims systems.

This position reports to the Director of Delivery Management and will work across a geographically dispersed team.

Your Impact

Leadership & Team Management

• 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.

Claims Ingestion Ownership

• 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.

Operational Excellence & Best Practices

• 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.

Incident, Issue & Change Management

• 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.

Reporting and Transparency

• Provide operational metrics, trend analysis, and SLA reporting to leadership and customers.
• Lead customer calls focused on ingestion performance, issue status, and optimization opportunities.

What You Bring

• 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.

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.

Geographic Responsibility: While HealthEdge is located in Boston, MA you may live anywhere in the US. Type of Employment: Full‑time, permanent

Work Environment: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job:

• The employee is occasionally required to move around the office. Specific vision abilities required by this job include close vision, color vision, peripheral vision, depth perception, and ability to adjust focus.
• Work across multiple time zones in a hybrid or remote work environment.
• Long periods of time sitting and/or standing in front of a computer using video technology.
• May require travel dependent on company needs.

The above statements are intended to describe the general nature and level of the job being performed by the individual(s) assigned to this position. They are not intended to be an exhaustive list of all duties, responsibilities, and skills required. HealthEdge reserves the right to modify, add, or remove duties and to assign other duties as necessary. In addition, reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of this position in compliance with the Americans with Disabilities Act of 1990. Candidates may be required to go through a pre‑employment criminal background check.

HealthEdge is an equal opportunity employer. We are committed to workforce diversity and actively encourage all qualified persons to seek employment with us, including, but not limited to, racial and ethnic minorities, women, veterans and persons with disabilities.

#LI‑Remote

** The annual US base salary range for this position is $110,000 to $130,000. This salary range may cover multiple career levels at HealthEdge. Final compensation will be determined during the interview process and is based on a combination of factors including, but not limited to, your skills, experience, qualifications and education.