Senior Director, Network and File Operations

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

📋 Description

• Oversee the comprehensive integration of hospital, physician, ancillary, and specialty networks into enterprise systems.

• Ensure the precise and prompt processing of provider demographics, contracts, fee schedules, reimbursement methodologies, participating status, and network tiering.

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

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

• Work alongside operational units, client managers, and hospital system clients to deliver scalable processes that meet client requirements.

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

• Develop multi-year roadmaps for digital transformation and integration scalability.

• Lead high-performing teams and cultivate leadership through mentoring, coaching, performance management, and constructive feedback.

• Set, communicate, and achieve team and individual objectives.

• Manage staffing decisions, onboarding, offboarding, promotions, compensation input, interviews, and recommendations.

• Supervise outbound file integration teams in implementing files for both new and existing point-solution vendors.

• Ensure compliance with data-sharing and security protocols for external vendors.

• Maintain relationships with key vendors and partners.

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

• Monitor metrics and comply with outbound file KPIs and client SLAs.

• Oversee documentation of the outbound file process.

• Manage the entire lifecycle of file integrations, encompassing requirements gathering, file layout design, mapping, validation, scheduling, and monitoring.

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

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

⛳️ Requirements

• Bachelor's Degree.

• 12 years of relevant business experience in TPA/Payer operations.

• 5 years of leadership experience.

• Capability to develop business strategy and translate it into actionable objectives and measurable outcomes.

• Ability to collaborate with product, operational, and IT teams.

• Extensive knowledge and experience in the healthcare/insurance sector.

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

• Practical experience supporting business operations utilizing the HealthEdge platform.

• Familiarity with claims administration, provider configuration, network management, enrollment, benefits, payment integrity, and associated operational workflows.

• Demonstrated success in partnering with business stakeholders to optimize HealthEdge-enabled processes and enhance 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 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.