Director of Eligibility OperationsThe OpportunityWe are looking for a Director of Eligibility Operations to own our eligibility function end to end. This is a senior leadership role responsible for product roadmap, platform integrity, operational performance, and cross-functional coordination across technology, adjudication, implementation, and client teams. You will be joining during an active period of platform development and migration, and will be expected to contribute to operational readiness and stability from day one.
What You Will OwnThe Director of Eligibility Operations is required to perform the following duties and professionally undertake the following responsibilities:
Product and Roadmap
- 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.
Platform and Migration
- Own the eligibility function's contribution to platform migration initiatives, including testing sign-off, migration validation, and post-go-live stability.
- Track and submit enhancement requests with documented business impact, following through from submission to delivery.
- Represent eligibility in platform governance and change control processes.
Operations and Performance
- Own error trend reporting, SLA tracking, and root cause analysis for recurring defects.
- Serve as the senior escalation authority for eligibility issues beyond the Manager and Analyst layers.
- Own Tier 2 support accountability; support Tier 3 resolution in coordination with the technology team.
- Keep the team's work visible to leadership through dashboards, reporting, or equivalent tools.
Leadership and Cross-Functional Impact
- Provide strategic oversight to the EDI/Eligibility Manager and maintain ultimate accountability for team performance and quality.
- Partner with Client Experience, Implementation, Adjudication, and QA teams on eligibility-related escalations and initiatives.
- Represent the eligibility function in client conversations and cross-functional leadership discussions
What We Are Looking ForRequired
- 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
Preferred
- Transparent or pass-through PBM experience.
- Familiarity with claims adjudication and eligibility management platforms.
- Background in product ownership, business systems analysis, or eligibility program management.
- Experience with Jira, Zendesk, Azure DevOps, or similar ticketing and workflow tools.
- URAC or NCQA operational compliance experience
What We Have to OfferOur benefits package is deigned to keep our employees happy and healthy - physically, mentally and financially.
- Medical, Dental Vision insurance
- Disability and Life insurance
- Employee Assistance Program
- Remote work options
- Annual Reviews and Development Plans
- Retirement Plan with company match immediately 100% vested.
