Data Exchange Manager - Claims Operations
About The Position
The Data Exchange Manager is responsible for leading day-to-day Data Exchange operations supporting both PBM and TPA (Medical, Dental and Vision) business lines. The role oversees analysts and specialists responsible for healthcare data integrations, client onboarding, EDI transactions, eligibility feeds, claims exchanges, configuration setup, data quality monitoring, and operational issue resolution. Manager will works closely with internal teams and external partners to design, maintain, and troubleshoot data exchange processes that support claims, formulary, network, and eligibility operations. Success in this role requires deep PBM and TPA data expertise, strong analytical and problem‑solving abilities, and the communication skills needed to drive alignment across JUDI Health and with our clients.
Requirements
- Bachelor’s degree or equivalent experience.
- 5+ years in healthcare data exchange, EDI, PBM or claims administration.
- Leadership experience within a PBM or healthcare setting, preferably managing high‑volume data exchange or interoperability functions.
- Knowledge of PBM and TPA data structures and healthcare EDI standards.
- Proficiency in SQL, Excel, and other analytical tools preferred.
- Exceptional analytical skills with the ability to diagnose root causes and propose effective solutions.
- Strong communication skills with the ability to build and maintain relationships across technical and non‑technical stakeholders.
- Highly organized, self‑motivated, and able to manage multiple priorities in a fast‑paced environment.
Responsibilities
- Lead and develop Data Exchange staff across PBM and TPA operations.
- Oversee connectivity setup and configuration activities for all new and existing clients.
- Oversee healthcare data exchange operations, connectivity, onboarding and production support.
- Manage PBM integrations including eligibility, claims, accumulator, formulary and network data.
- Oversee TPA EDI transactions including 834, 837, 835, 270/271, 276/277 and 278.
- Ensure data quality, reconciliation, audits and issue resolution.
- Partner with Implementations, Client Services, Product, Engineering and external trading partners.
- Drive automation, process improvement and operational excellence.
- Ensure HIPAA and regulatory compliance.
- Serve as a central coordination point for issue identification, triage, and resolution across internal teams and external integration partners.
- Monitor system status, data movement, and platform dashboards to proactively detect abnormalities impacting quality or performance.
- Ensure all data exchange issues are remediated according to established SLAs, operating standards, and audit controls.
- Perform and oversee audits and reconciliation processes to validate data integrity across systems.
- Partner with Implementation, Operations, Client Success, Product, and Engineering to support client onboarding, migrations, vendor changes, and enhancement requests.
- Act as a liaison across business areas to ensure alignment, clear communication, and coordinated prioritization.
- Translate business requests into technical requirements, assess complexity, and support accurate effort estimation and SLA assignment.
- Identify opportunities to streamline workflows, enhance data quality, and reduce operational risk through automation and process refinements.
- Develop and maintain comprehensive documentation—including policies, procedures, and configuration standards for JUDI system operations.
- Stay current with Medicare, Medicaid, and state regulatory requirements to ensure all data exchange processes remain compliant.
- Follow and reinforce the JUDI Health Code of Conduct, including escalation and reporting of noncompliance when appropriate.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
