Manager, Healthcare Data Quality and Audit

Imagine360•,

7d•$100,000 - $120,000•Remote

About The Position

Imagine360 is seeking a Manager, Healthcare Data Quality and Audit to join the team! The Manager, Healthcare Data Quality and Audit is responsible for leading healthcare and pharmacy data QA, data quality oversight, reconciliation, accuracy, and integrity of inbound and outbound healthcare data files, including 834, 837, 270, 271, 276 and 277 transactions, pharmacy claims, accumulator, and partner interface data across Imagine360 systems and Pharmacy Benefit Manager (PBM) partners. This role provides leadership for healthcare data monitoring, audit controls, discrepancy resolution, vendor accountability, and continuous improvement while managing and coaching a team of 10+ onshore and offshore resources. The Manager will oversee healthcare data integrity processes, inbound and outbound EDI data validation, pharmacy claims quality controls, and timely identification and resolution of data quality issues. This role partners closely with technology teams, claims operations, implementation teams, PBM vendors and business stakeholders to establish scalable controls, reporting standards, production monitoring practices, and operational processes that support accurate data transmission, benefit tracking, claims adjudication integrity, downstream system accuracy, and effective team performance across distributed teams. Position Location: 100% remote

Requirements

Bachelor's degree in business administration, Healthcare Administration, Information Systems, Data Analytics, Finance, or related field; or equivalent work experience.
10+ years of experience in healthcare claims, pharmacy operations, PBM data QA, healthcare data analysis, auditing, reconciliation, benefit administration, or partner interface support.
Hands-on knowledge of inbound and outbound healthcare data transactions and file exchanges, including 834, 837, 270, 271, 276 and 277 transaction types.
Strong working knowledge of pharmacy claims operations, pharmacy benefit administration, PBM workflows, claims adjudication concepts, accumulator processes, and pharmacy data reconciliation.
Experience working with pharmacy claims data, accumulators, PBM reporting, or healthcare data feeds.
Experience managing and leading 10+ onshore and offshore resources.
Demonstrated leadership and coaching experience, including mentoring team members, setting priorities, managing workload distribution, and developing team performance.
Experience leading data reconciliation, audit controls, issue resolution, and root cause analysis.
Experience coordinating cross-functional work with business, technical, vendor, and operational teams.
Technical proficiency in SQL queries, data analysis, source-to-target validation, data mapping, and record-level reconciliation to support healthcare data quality and root cause analysis.
Experience monitoring SFTP file exchanges, automated data feeds, missing or delayed files, transmission failures, and vendor-related data exchange issues.
Ability to develop and use data quality controls, exception reports, dashboards, and KPI reporting through tools such as Excel, Power BI, SQL, or similar reporting platforms.
Prior experience creating reports, exception tracking, process documentation, or executive-level status updates.

Nice To Haves

Advanced degree or certification in healthcare administration, data analytics, process improvement, or related discipline preferred.
Experience working directly with healthcare partner interfaces, PBMs and pharmacy vendors, including data exchange validation, operational issue resolution, and vendor accountability.
Experience supporting healthcare data integrations, EDI transactions, SFTP file feeds, or automated data exchange processes.
Experience with SQL, Power BI, data analytics tools, or reporting platforms.
Familiarity with GBAS, VBA, or similar healthcare claims platforms.
Knowledge of pharmacy benefit administration, accumulator management, and claims adjudication.
Prior experience supervising analysts, leading distributed teams, managing offshore delivery, or overseeing operational workflows across multiple resources.
Experience in process improvement, production monitoring, audit control design, or vendor performance management.

Responsibilities

Manage, lead, coach, and develop a team of 10+ onshore and offshore resources supporting Healthcare data QA, pharmacy data QA, reconciliation, audit controls, and production monitoring.
Provide day-to-day leadership, workload prioritization, performance guidance, and accountability to ensure timely, accurate, and high-quality delivery across distributed teams.
Mentor team members, build technical and operational capabilities, promote knowledge sharing, and support skill development across Healthcare data integrity, QA practices, root cause analysis, and vendor issue management.
Establish team operating rhythms, quality expectations, escalation protocols, and communication practices to support consistent execution across onshore and offshore resources.
Provide Strategic leadership oversight for pharmacy data integrity processes, ensuring accurate receipt, validation, reconciliation, and transmission of pharmacy claims, accumulator, eligibility, and healthcare data across internal and external systems.
Oversee governance and quality assurance of inbound and outbound healthcare transactions, including 834 Eligibility, 837 Claims, 270 Eligibility Inquiry, 271 Eligibility Response, and 276 /277 Claim Status files, ensuring data accuracy, completeness, compliance, and operational readiness.
Lead investigations of pharmacy data discrepancies, accumulator variances, and PBM reporting issues, partnering with business, technology, and vendor teams to drive resolution and corrective actions.
Drive resolution of pharmacy claims, accumulator, eligibility, and data transmission issues through collaboration with PBMs, technology teams, claims operations, implementation teams, and business stakeholders.
Establish scalable controls, monitoring practices, reporting standards, reconciliation procedures, and audit frameworks that improve pharmacy data accuracy, vendor accountability, regulatory compliance, and audit readiness.
Lead continuous improvement initiatives focused on automation, data quality, reconciliation effectiveness, pharmacy claims operations, PBM integration performance, and operational efficiency.
Oversee reconciliation and audit processes to ensure pharmacy, claims, eligibility, and EDI transaction data is accurately received, processed, validated, transmitted, and reflected across Imagine360 claim adjudication systems. (Including GBAS, VBA, PBM platforms, and downstream systems.)
Establish and maintain pharmacy data integrity controls, reconciliation procedures, audit standards, quality checkpoints, reporting templates, and escalation processes.
Develop quality controls for inbound and outbound file exchanges, including file receipt validation, outbound transmission checks, data completeness, data mapping accuracy, record-level exception review, and audit traceability.
Ensure compliance with data governance, security, privacy, regulatory, and audit-readiness requirements related to pharmacy data operations.
Develop and maintain process documentation, SOPs, control logs, evidence repositories, and audit-ready materials to support internal reviews, external audits, and operational governance.
Manage production monitoring activities for Medical, pharmacy claims data, PBM data feeds, and inbound/outbound EDI transactions, identifying processing failures, data anomalies, missing files, rejected records, delayed transmissions, quality gaps, and operational risks.
Lead root cause analysis for pharmacy data discrepancies and coordinate corrective action plans with internal teams, PBM partners, vendors, and technology stakeholders.
Support incident investigations, client impact analysis, remediation tracking, and resolution of healthcare data(pharmacy+ Medical) related operational escalations.
Monitor key healthcare data quality metrics, identify trends, and report risks, issues, outcomes, and remediation plans to leadership.
Ensure timely and accurate distribution of recurring reconciliation, exception, operational, quality, and leadership reporting.
Drive continuous improvement initiatives focused on automation, audit effectiveness, operational efficiency, quality controls, standardization, and reduction of manual reconciliation risk.
Identify opportunities to improve Healthcare data QA processes, data governance practices, vendor accountability, production monitoring, and operational transparency.
Perform other duties as assigned.

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