Senior Director, Network and File Operations

This is a fully remote position, open to applicants in United States.

📋 Description

• Oversee the comprehensive integration of hospitals, physicians, ancillary services, and specialty networks into enterprise systems.

• Ensure the precise and timely management of provider demographics, contracts, fee schedules, reimbursement methodologies, participation status, and network tiering.

• Collaborate with EDI and Network Operations teams to maintain data file flows and standards, identify points of failure, and address monitoring alerts.

• Create standardized workflows for network onboarding, mapping, quality assurance, and validation.

• Work in partnership with operational units, client managers, and hospital system clients to establish scalable network processes.

• Drive the modernization, standardization, governance, automation, quality, and compliance of provider and file integration.

• Define multi-year digital transformation and integration scalability roadmaps.

• Lead high-performing teams, establishing, communicating, and achieving team and individual objectives.

• Mentor, coach, motivate, evaluate, and oversee direct reports.

• Make staffing decisions, including onboarding, offboarding, promotions, and candidate recommendations.

• Supervise outbound file integration teams that implement files for point-solution vendors.

• Ensure compliance with data-sharing and security protocols.

• Maintain relationships with key vendors and partners.

• Collaborate with IT to manage and resolve daily file integration issues.

• Monitor metrics and ensure compliance with outbound-file KPIs and client SLAs.

• Oversee the documentation of outbound file processes.

• Manage file integration lifecycles, including requirements gathering, file layout design, mapping, validation, scheduling, and monitoring.

• Establish SLAs for delivery, error resolution, and quality control.

• Assess technologies, automation tools, and integration platforms to enhance operational performance.

⛳️ Requirements

• Bachelor’s Degree and 12 years of relevant business experience in TPA/Payer operations.

• 5 years of leadership experience.

• Capability to develop business strategies and translate them into actionable objectives and measurable outcomes with product, operational, and IT partners.

• Extensive understanding of and experience in the healthcare/insurance sector.

• Experience implementing Lean process methodologies to enhance operational efficiency.

• Background in network integration, provider maintenance, and outbound file integration.

• Practical experience supporting business operations utilizing the HealthEdge platform, including claims administration, provider configuration, network management, enrollment, benefits, payment integrity, and related workflows.

• Demonstrated success in partnering with business stakeholders to optimize HealthEdge-enabled processes, drive operational efficiency, and enhance service delivery.

• Familiarity with healthcare data interchange formats, including X12 EDI transactions 834, 835, 837, 820, 270/271, 276/277, 999, and associated companion guides.

• Ability to interpret vendor file specifications and guide teams through mapping, validation, balancing, and certification processes.

• Remote employees must reside 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.