Senior Manager, Electronic Data Interchange and Claims Data Operations

L.A. Care Health Plan•Los Angeles, CA

About The Position

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.

Requirements

Bachelor's Degree In lieu of degree, equivalent education and/or experience may be considered.
At least 6 years of experience working with healthcare data, EDI transactions, claims data operations, or managed-care administrative systems.
At least 5years of experience in leading, supervising and/or managing staff.
Experience with system integrations, data migrations, or large-scale technical implementations.
Demonstrated experience leading complex issue resolution and root cause analysis efforts.
Experience leading teams, projects, initiatives, or cross-functional groups
Strong knowledge of HIPAA-standard EDI transactions and healthcare data structures.
Knowledge of MOOP accumulators, authorization workflows, and EOB data flows.
Familiarity with claims adjudication rules, cost-share logic, and benefit application.
Proficiency in SQL, Access, Excel, and related reporting or analysis tools.
Ability to interpret and produce BRDs, FRDs, process flows, and technical documentation.
Strong analytical, problem-solving, and system-thinking skills.
Strong interpersonal skills for building relationships, fostering teamwork, and creating a positive work environment. Ability to guide and support team members.
Excellent attention to detail and ability to manage multiple priorities and tight deadlines.
Excellent ability to set clear goals, develop strategic plans to achieve those goals, and inspire others to work towards a shared vision.
Skilled in mediating disputes and resolving conflicts in a fair and constructive manner.
Ability to develop and manage budgets, forecast future financial outcomes, and make informed decisions about resource allocation.
Demonstrated ability to make informed decisions.
Excellent verbal, written communication, and presentation skills.
Deep understanding of the industry, market dynamics, and organizational operations to identify opportunities and navigate challenges.
Strong ability to analyze market trends, anticipate future changes, and develop long-term strategies that align with the company's goals.

Nice To Haves

Master's Degree in Business Administration or Related Field
Experience developing test cases, leading UAT, or supporting system configuration changes.
Experience with commercial health plan operations or delegated partner management.
Working knowledge of relational databases, system interfaces, or data transformation logic.
Experience with delegated entity data submissions or clearinghouse integrations.

Responsibilities

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 requirements. Troubleshoots and resolves EOB-related issues, including cost-share miscalculations, missing data, formatting discrepancies, and system defects. Supports testing of EOB templates, logic updates, and system enhancements that impact EOB accuracy and delivery.
Leads complex root cause analyses for issues impacting claims data, authorizations, accumulators, or EOBs.Duties ContinuedCoordinates remediation efforts with cross-functional departments. Implements and provides guidance to the departmental and organizational processes and policies and works with senior and/ or executive management to define, prioritize, and develop projects and programs.
Ensures corrective actions are documented, validated, and monitored to prevent recurrence. Identifies systemic issues and recommends upstream solutions to strengthen operational controls and improve accuracy.
Responsible for Identifying complex problems and reviewing related information to develop and evaluate options and implement solutions. Manages complex projects, engaging and updating key stakeholders, developing timelines, leads others to complete deliverables on time and ensures implementation upon approval. Leads process and workflow redesign efforts to increase automation, reduce manual work, and improve overall data quality.
Oversees User Acceptance Testing (UAT) planning, test case creation, execution, and validation for system changes affecting EDI, authorization data, accumulators, and EOBs.
Ensures strong quality gates are consistently applied before production releases.
Works closely with the Director, EDI to prioritize enhancements and support operational readiness for system changes.
Serves as an operational liaison to cross-functional departments and delegated entities.
Communicates system availability, planned changes, incident statuses, and file processing updates clearly and consistently.
Supports internal and external partners with non-standard data requests, testing analysis, and troubleshooting.
Manages staff and the day-to-day activities in the department. Participates in the department budgeting process. Responsible for scheduling, training, performance, corrective actions, mentoring, and developing of the team(s). Foster and promote a culture of transparency, continuous improvement, accountability, and shared ownership of enterprise goals. Mentors and develops staff, building technical and critical thinking skills across the team. Responsible for overseeing and managing the budgets of their respective departments.
Maintains a culture of rigor, transparency, analytical curiosity, proactive issue identification, cross-functional communication, accountability, and continuous operational improvement.
Perform other duties as assigned.