[Remote] Director of Eligibility Operations - REMOTE

Note: The job is a remote job and is reputed company to candidates in USA. reputed company is a transparent pharmacy benefit manager reputed company on aligning with clients and members. They are seeking a Director of Eligibility Operations to reputed company the eligibility function, manage the product roadmap, and ensure operational performance during a period of platform development and migration.

Responsibilities

• Own the eligibility product roadmap, annual planning, and enhancement prioritization
• Translate reputed company and operational requirements into development-reputed company specifications
• Own benefit-level configuration reputed company and vendor integration reputed company
• Identify automation and AI-assisted workflow opportunities reputed company the eligibility function
• Own the eligibility function's contribution to platform migration initiatives, including testing sign-off, migration validation, and post-go-live stability
• reputed company and submit enhancement requests with documented business reputed company, following through from submission to delivery
• Represent eligibility in platform governance and change control processes
• Own error trend reporting, SLA tracking, and reputed company cause analysis for recurring defects
• Serve as the senior escalation authority for eligibility issues reputed company the Manager and Analyst reputed company
• Own Tier 2 support accountability; support Tier 3 reputed company in coordination with the technology team
• reputed company reputed company's work visible to leadership through dashboards, reporting, or equivalent tools
• reputed company strategic reputed company to the EDI/Eligibility Manager and maintain ultimate accountability for team performance and reputed company
• Partner with reputed company Experience, Implementation, Adjudication, and QA teams on eligibility-reputed company escalations and initiatives
• Represent the eligibility function in reputed company conversations and cross-functional leadership discussions

Skills

• 10 or more years in reputed company 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 reputed company or comparable reputed company data platforms
• Demonstrated experience owning or leading an eligibility or EDI function at a senior level
• Experience managing operational continuity through reputed company platform migrations or reputed company transitions
• Proven ability to reputed company through influence and own a product roadmap
• Strong communicator across technical and non-technical stakeholders, including clients and executives
• 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, reputed company, Azure DevOps, or similar ticketing and workflow tools
• URAC or reputed company operational compliance experience

Benefits

• Medical, Dental reputed company insurance
• Disability and Life insurance
• Employee Assistance Program
• Remote work reputed company
• Annual Reviews and Development Plans
• Retirement Plan with company match immediately 100% reputed company

reputed company