Director of Eligibility Operations

Responsibilities

• Own the eligibility product roadmap, annual planning, and enhancement prioritization.
• Translate client and operational requirements into development-ready specifications.
• Own benefit-level configuration oversight and vendor integration strategy.
• Identify automation and AI‑assisted workflow opportunities within the eligibility function.
• Own the eligibility function's contribution to platform migration initiatives, including testing sign‑off, migration validation, and post‑go‑live stability.
• Keep the team's work visible to leadership through dashboards, reporting, or equivalent tools.
• Provide strategic oversight to the EDI/Eligibility Manager and maintain ultimate accountability for team performance and quality.
• Represent the eligibility function in client conversations and cross‑functional leadership discussions.

Qualifications

• 10 or more years in healthcare eligibility, EDI operations, or PBM/health plan benefit administration.
• Expert knowledge of X12 834 and 270/271 transaction sets with hands‑on troubleshooting experience.
• Working SQL proficiency and familiarity with Snowflake or comparable cloud data platforms.
• Demonstrated experience owning or leading an eligibility or EDI function at a senior level.
• Experience managing operational continuity through active platform migrations or system transitions.
• Proven ability to lead through influence and own a product roadmap.
• Strong communicator across technical and non‑technical stakeholders, including clients and executives.

Core Competencies

Demonstrates extensive expertise in healthcare eligibility and EDI operations, with a strong focus on product roadmap ownership, strategic oversight, and cross‑functional leadership. Proficient in managing platform migrations and leveraging automation to enhance operational efficiency.

Tools & Technologies

• SQL
• Snowflake
• Dashboards
• Reporting Tools