Senior Operations Specialist

Imagine360 is seeking a Senior Operations Specialist to join the team! We are looking for an experienced operations professional with deep expertise in EDI (Electronic Data Interchange), specifically HIPAA 834 Enrollment and 837 Claims transactions, to lead implementation efforts and provide strategic operational support for third-party administrator (TPA) partnerships.

This role serves as the operational lead for new TPA onboarding, overseeing implementation projects from planning through production while ensuring seamless integration, testing, and long-term operational success. The Senior Operations Specialist will act as the primary operational liaison for TPAs, lead cross-functional initiatives, identify process improvements, and provide subject matter expertise on EDI transaction workflows.

Position Location: 100% remote

Responsibilities include but are not limited to:

• EDI Implementation Support:
  • 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.
  • Coordinate 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.
• Production Support & Operational Oversight:
  • 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.
• Cross-Functional Collaboration:
  • Serve as the subject matter expert for 834 and 837 transaction workflows and related operational processes.
  • Partner with Finance, Claims Audit, IT, Client Implementations, Client Experience, and Member Services to resolve complex operational challenges.
  • Provide guidance and operational expertise during new client and partner implementations.
  • Facilitate communication across departments to ensure alignment on project priorities, issue resolution, and service delivery expectations.
  • Mentor team members by sharing best practices and supporting knowledge transfer related to EDI operations and TPA management.
• Process Documentation & SOP Development:
  • Develop, maintain, and enhance SOPs, implementation playbooks, and operational documentation.
  • Identify opportunities to improve workflows, increase automation, and standardize operational processes.
  • Recommend enhancements to existing implementation methodologies based on lessons learned and industry best practices.
  • Ensure documentation remains current, scalable, and accessible across teams.
• Partner Relationship Management:
  • 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:
• Required:
  • 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

What can Imagine360 offer you?

• 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

Want to see our latest job opportunities? Follow us on LinkedIn

Imagine360 is a health plan solution company that combines 50+ years of self-funding healthcare expertise. Over the years, we've helped thousands of employers save billions on healthcare. Our breakthrough total health plan solution is fixing today's one-size-fits-none PPO insurance problems with powerful, customized, member-focused solutions.

Imagine360 is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or veteran status.

**RECRUITMENT AGENCIES PLEASE NOTE: Imagine360 will only accept applications from agencies/business partners that have been invited to work on a specific role. Candidate Resumes/CV's submitted without permission or directly to Hiring Managers will be considered unsolicited and no fee will be payable. Thank you for your cooperation**