Healthcare Claims Operations Manager

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 con