Senior Manager, Electronic Data Interchange and Claims Data Operations

Salary Range:  $117,509.00 (Min.) - $152,762.00 (Mid.) - $188,015.00 (Max.)

 

Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time.

Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.
 

Job Summary

The Senior Manager, Electronic Data Interchange (EDI) & Data Operations is responsible for leading and optimizing the day-to-day operational, analytical, and technical functions that support electronic data exchange, authorization data ingestion, accumulator management, and Explanation of Benefits (EOB) processing for L.A. Care. This includes operational oversight of all Health Insurance Portability and Accountability Act (HIPAA) standard and proprietary EDI transactions, delegated and internal authorization data loads, accumulator workflows, and the operational components of EOB generation and remediation.

 

The Senior Manager oversees a team who manage file intake, data validation, routing, reconciliation, testing, and issue resolution across the enterprise. This position ensures that all electronic and paper-to-electronic data supporting claims and administrative operations is accurate, timely, and compliant with regulatory, contractual, and quality expectations.

 

This position plays a critical leadership role in enhancing upstream controls, reducing rework, improving automation, supporting system changes, and driving continuous improvement in data operations.

 

Manages all aspects of running an efficient team, including hiring, supervising, coaching, training, disciplining, and motivating direct reports.  Responsible for driving performance to ensure that the team can lead high-level decisions that impact on the success of L.A. Care.  Oversees the development, implementation, administration, and maintenance of the department's programs, policies, and procedures. Responsible for driving management and performance to ensure that the team can lead high-level decisions that impact on the success of L.A. Care.

 

Collaborate closely with executive/ senior management to establish goals that align with the company’s mission and vision.

Duties

Strengthens the reliability, accuracy, and efficiency of all electronic data processes that support claims operations, ensuring data flows through systems as intended, issues are rapidly identified and remediated, and upstream controls are continuously enhanced. Helps drive predictable outcomes, improve payment accuracy, and maintain regulatory readiness across the data ecosystem.

 

Manages end-to-end operational oversight of all inbound and outbound HIPAA-standard and proprietary EDI transactions (837, 835, 270/271, 276/277, 834, 278). Ensures timely, accurate, and compliant processing of electronic claims, encounters, eligibility updates, and related administrative data.

 

Oversees transaction monitoring, exceptions, error queues, and data rejects; ensures prompt triage and resolution. Provides oversight of requirements documentation, including business and functional requirements (BRDs/FRDs), workflow mapping, and data specifications that support operational effectiveness.

 

Plans and implements systems and procedures to maximize operating efficiency and achieve strategic priorities. 

 

Leads oversight of delegated Electronic Load of Delegated Authorizations (ELDA) and internal clinical authorization data loads into QNXT. Ensures authorization data is timely, complete, reconciled, and supportive of accurate claims adjudication.

 

Monitors authorization load success rates and partners with upstream teams to resolve recurring issues. Guides enhancements that reduce manual lookup burden for claims and increase automation.

 

Manages operational components of the Member Out-of-Pocket (MOOP) accumulator workflow, including reconciliation, error correction, escalation management, and member remediation.

 

Ensures accumulator data is accurate across intake systems, accumulator databases, QNXT, and output files.

 

Provides reporting and trending on accumulator performance, error patterns, and upstream causes.

 

Shares responsibility with the Director, EDI for operational oversight of EOB generation, validation, and data flow.

 

Ensures EOB output files reflect accurate benefit application, share of cost, accumulation, claim decisions, and meets regulatory requ