Sr. Lead, Payer Gateway Management

Location:Hybrid 3 days (offices in NYC, Denver, CO and Charlotte, NC area)

Position Summary:

The Senior Lead Payer Gateway Management oversees electronic healthcare transaction processing between payers, providers, clearinghouses, vendors, and internal TPA adjudication platforms. This role ensures accurate, timely, and compliant processing of HIPAA EDI transactions and hosted gateway solutions supporting claim submissions, eligibility verification, claims status checks, acknowledgments, rejections, file reconciliation, and production issue resolution.

The Senior Lead serves as an operational and technical bridge across Claims, IT/EDI, Clearinghouse Operations, Provider Relations, Client Implementation, Vendors, and Compliance. The role is accountable for transaction reliability, trading-partner readiness, file controls, root-cause remediation, and continuous improvement of gateway performance for medical claims administration.

Position Responsibilities:

• Oversee payer gateway and clearinghouse operations supporting HIPAA EDI transactions, including 837 claims, 270/271 eligibility, 276/277 claims status, 835 remittance/payment support, acknowledgments, rejects, and related file exchanges.
• Ensure claim submissions are routed, accepted, monitored, and reconciled timely to support accurate TPA adjudication and minimize provider abrasion, duplicate submissions, avoidable rejects, and processing delays.
• Manage daily operational controls for inbound/outbound files, transaction queues, acknowledgments, trading-partner responses, exception reports, file balancing, resubmission workflows, and aging items.
• Lead issue triage and root-cause analysis for transaction failures, clearinghouse rejects, payer/provider setup defects, connectivity issues, mapping errors, enrollment gaps, duplicate files, missing acknowledgments, or reconciliation breaks.
• Partner with IT/EDI, claims system teams, clearinghouses, vendors, and trading partners to define requirements, test transaction flows, maintain payer/provider routing logic, and validate gateway changes before production release.
• Support client implementations, new payer IDs, provider/trading-partner onboarding, clearinghouse migrations, product/network launches, and hosted solution changes by ensuring EDI/gateway readiness and post-go-live monitoring.
• Maintain SOPs, runbooks, escalation paths, file-control matrices, trading-partner inventories, payer ID/routing documentation, reconciliation standards, SLAs, and operational dashboards.
• Monitor gateway performance metrics, identify trends, communicate risks, and lead continuous improvement initiatives to strengthen transaction acceptance, throughput, compliance, and operational transparency.
• Ensure processes align with HIPAA transaction standards, organizational security/privacy expectations, audit requirements, business continuity expectations, and contractual service commitments.
• Serve as a senior subject matter expert and mentor for analysts/specialists handling EDI operations, clearinghouse inquiries, provider gateway issues, and production support.

Required Qualifications:

• Bachelor’s degree in healthcare administration, business, information systems, analytics, or a related field
• 6+ years of experience in healthcare EDI, payer gateway operations, clearinghouse operations, claims operations, revenue cycle transaction support, or payer/TPA technology operations.
• Strong working knowledge of HIPAA EDI transaction workflows, especially 837, 270/271, 276/277, 835, acknowledgments, rejection handling, trading-partner enrollment, and file reconciliation concepts.
• Experience supporting medical claim submission workflows into payer or TPA adjudication platforms, including issue triage across providers, clearinghouses, payer IDs, routing tables, and claims systems.
• Demonstrated ability to manage operational queues, reconciliations, exception reports, SLAs, production incidents, root-cause analysis, and cross-functional corrective action plans.
• Ability to translate technical EDI/gateway issues into business impacts for Claims, Provider Relations, Client Services, Compliance, IT, vendors, and leadership.
• Proficiency with Excel, reporting tools, ticketing/workflow systems, secure file transfer concepts, data validation, and operational dashboarding.

Preferred Qualifications:

• Experience in a medical TPA, health plan, PPO/network, ASO/self-funded employer, clearinghouse, claims platform, or managed-care operations environment.
• Experience with payer ID management, provider EDI enrollment, SFTP/API file exchange, X12 validation tools, claims-adjudication platforms, clearinghouse portals, and vendor-hosted gateway solutions.
• Familiarity with X12 loops/segments, companion guides, 999/277CA acknowledgments, 824/TA1 concepts, COB workflows, encounter/data extracts, and remittance/payment file operations.
• Experience leading implementation readiness, trading-partner testing, production cutovers, clearinghouse migrations, issue-command centers, or operational stabilization efforts.
• Healthcare operations, EDI, project management, Lean/Six Sigma, compliance, or analytics training/certification are a plus.