Senior Operations Specialist

Responsibilities

• Lead end-to-end operational onboarding of new TPAs, managing implementation timelines, deliverables, risks, and cross-functional coordination.
• Serve as the operational project manager for EDI implementations involving 834 Enrollment and 837 Claims transactions.
• Lead technical and operational meetings with TPAs and internal stakeholders throughout implementation.
• Oversee testing and validation of inbound and outbound EDI files to ensure compliance with HIPAA standards, partner specifications, and business requirements.
• Cookordination implementation activities across Operations, IT, Finance, Claims Audit, Client Implementations, Client Experience, and Member Services to ensure successful go-live.
• Identify implementation risks, proactively develop mitigation strategies, and drive timely resolution of issues.
• Serve as the primary operational owner for assigned TPA relationships following implementation.
• Monitor production performance and proactively identify opportunities to improve transaction quality, turnaround times, and operational efficiency.
• Investigate and resolve complex production issues involving claims routing, enrollment, file processing, and eligibility discrepancies.
• Lead root cause analysis for recurring issues and partner with technical and business teams to implement long-term corrective actions.
• Track operational metrics, partner performance, and implementation outcomes, providing recommendations for continuous improvement.
• Build and maintain strong operational relationships with third-party administrators.
• Lead recurring operational business reviews with TPAs to discuss implementation status, production performance, claims aging, open issues, and service improvements.
• Serve as the escalation point for complex operational concerns requiring cross-functional coordination.
• Maintain detailed implementation documentation, issue logs, and action plans through project completion.

Qualifications

• Bachelor's degree or equivalent combination of education and experience.
• 3-5+ years of experience supporting healthcare EDI operations with significant hands-on experience managing HIPAA 834 Enrollment and 837 Claims transactions.
• Demonstrated experience leading or project managing EDI implementations and onboarding new TPAs or healthcare trading partners.
• Strong understanding of healthcare claims processing, eligibility and enrollment workflows, and TPA operations.
• Proven ability to independently manage multiple implementation projects and competing priorities in a fast-paced environment.
• Excellent project management, communication, organizational, analytical, and problem-solving skills.
• Experience collaborating across technical and business teams to drive successful implementation outcomes.
• Preferred: Experience working with healthcare clearinghouses, EDI mapping tools, or healthcare integration platforms.
• Knowledge of payer systems, claims adjudication processes, and healthcare interoperability standards.
• Experience developing SOPs, implementation documentation, and operational playbooks.
• Experience analyzing operational metrics and producing performance reporting.
• Previous experience mentoring team members or serving as a functional subject matter expert.

Skills and Abilities

• SQL and Excel

Benefits

• Multiple Health plan options
• Company paid employee premiums for disability and life insurance
• Parental Leave Policy
• 20 days PTO to start / 10 Paid Holidays
• Tuition reimbursement
• 401k Company contribution
• Company paid Short & Long term Disability plus Life Insurance
• Professional development initiatives / continuous learning opportunities
• Opportunities to participate in and support the company's diversity and inclusion initiatives