L.A. Care Health Plan · 1 hour ago
Senior Manager, Electronic Data Interchange and Claims Data Operations
Los Angeles, CA
Full-time
Onsite
Senior Level
$118K/yr - $188K/yr
6+ years expL.A. Care Health Plan is the nation’s largest publicly operated health plan, established to provide health coverage to low-income Los Angeles County residents. The Senior Manager, Electronic Data Interchange and Claims Data Operations is responsible for leading operational, analytical, and technical functions related to electronic data exchange and claims processing, ensuring accuracy and compliance with regulatory standards.
FitnessGovernmentHealth Care
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
Coordinates 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
Qualification
Required
Bachelor's Degree
At least 6 years of experience working with healthcare data, EDI transactions, claims data operations, or managed-care administrative systems
At least 5 years 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
Preferred
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
Benefits
Paid Time Off (PTO)
Tuition Reimbursement
Retirement Plans
Medical, Dental and Vision
Wellness Program
Volunteer Time Off (VTO)
Company
L.A. Care Health Plan
L.A. Care’s mission is to provide access to quality health care for L.A.
1001-5000 employees
H1B Sponsorship
L.A. Care Health Plan has a track record of offering H1B sponsorships. Please note that this does not
guarantee sponsorship for this specific role. Below presents additional info for your
reference. (Data Powered by US Department of Labor)
Distribution of Different Job Fields Receiving Sponsorship
Represents job field similar to this job
Trends of Total Sponsorships
2024 (1)
2023 (1)
2021 (3)
2020 (1)
Funding
Current Stage
Late StageLeadership Team
Melanie Rainer
Chief Strategy and Transformation Officer
Recent News
MarketScreener
2025-08-27
2025-08-04
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