[Hiring] Manager, Healthcare Data Quality and Audit @Imagine360

Role Description

Imagine360 is seeking a Manager, Healthcare Data Quality and Audit to join the team! The Manager, Healthcare Data Quality and Audit is responsible for leading healthcare and pharmacy data QA, data quality oversight, reconciliation, accuracy, and integrity of inbound and outbound healthcare data files, including 834, 837, 270, 271, 276 and 277 transactions, pharmacy claims, accumulator, and partner interface data across Imagine360 systems and Pharmacy Benefit Manager (PBM) partners. This role provides leadership for healthcare data monitoring, audit controls, discrepancy resolution, vendor accountability, and continuous improvement while managing and coaching a team of 10+ onshore and offshore resources.

The Manager will oversee healthcare data integrity processes, inbound and outbound EDI data validation, pharmacy claims quality controls, and timely identification and resolution of data quality issues. This role partners closely with technology teams, claims operations, implementation teams, PBM vendors, and business stakeholders to establish scalable controls, reporting standards, production monitoring practices, and operational processes that support accurate data transmission, benefit tracking, claims adjudication integrity, downstream system accuracy, and effective team performance across distributed teams.

Position Location: 100% remote

Responsibilities include but are not limited to:

• Manage, lead, coach, and develop a team of 10+ onshore and offshore resources supporting Healthcare data QA, pharmacy data QA, reconciliation, audit controls, and production monitoring.
• Provide day-to-day leadership, workload prioritization, performance guidance, and accountability to ensure timely, accurate, and high-quality delivery across distributed teams.
• Mentor team members, build technical and operational capabilities, promote knowledge sharing, and support skill development across Healthcare data integrity, QA practices, root cause analysis, and vendor issue management.
• Establish team operating rhythms, quality expectations, escalation protocols, and communication practices to support consistent execution across onshore and offshore resources.
• Provide strategic leadership oversight for pharmacy data integrity processes, ensuring accurate receipt, validation, reconciliation, and transmission of pharmacy claims, accumulator, eligibility, and healthcare data across internal and external systems.
• Oversee governance and quality assurance of inbound and outbound healthcare transactions, including 834 Eligibility, 837 Claims, 270 Eligibility Inquiry, 271 Eligibility Response, and 276 /277 Claim Status files, ensuring data accuracy, completeness, compliance, and operational readiness.
• Lead investigations of pharmacy data discrepancies, accumulator variances, and PBM reporting issues, partnering with business, technology, and vendor teams to drive resolution and corrective actions.
• Drive resolution of pharmacy claims, accumulator, eligibility, and data transmission issues through collaboration with PBMs, technology teams, claims operations, implementation teams, and business stakeholders.
• Establish scalable controls, monitoring practices, reporting standards, reconciliation procedures, and audit frameworks that improve pharmacy data accuracy, vendor accountability, regulatory compliance, and audit readiness.
• Lead continuous improvement initiatives focused on automation, data quality, reconciliation effectiveness, pharmacy claims operations, PBM integration performance, and operational efficiency.
• Oversee reconciliation and audit processes to ensure pharmacy, claims, eligibility, and EDI transaction data is accurately received, processed, validated, transmitted, and reflected across Imagine360 claim adjudication systems.
• Establish and maintain pharmacy data integrity controls, reconciliation procedures, audit standards, quality checkpoints, reporting templates, and escalation processes.
• Develop quality controls for inbound and outbound file exchanges, including file receipt validation, outbound transmission checks, data completeness, data mapping accuracy, record-level exception review, and audit traceability.
• Ensure compliance with data governance, security, privacy, regulatory, and audit-readiness requirements related to pharmacy data operations.
• Develop and maintain process documentation, SOPs, control logs, evidence repositories, and audit-ready materials to support internal reviews, external audits, and operational governance.
• Manage production monitoring activities for Medical, pharmacy claims data, PBM data feeds, and inbound/outbound EDI transactions, identifying processing failures, data anomalies, missing files, rejected records, delayed transmissions, quality gaps, and operational risks.
• Lead root cause analysis for pharmacy data discrepancies and coordinate corrective action plans with internal teams, PBM partners, vendors, and technology stakeholders.
• Support incident investigations, client impact analysis, remediation tracking, and resolution of healthcare data (pharmacy + Medical) related operational escalations.
• Monitor key healthcare data quality metrics, identify trends, and report risks, issues, outcomes, and remediation plans to leadership.
• Ensure timely and accurate distribution of recurring reconciliation, exception, operational, quality, and leadership reporting.
• Drive continuous improvement initiatives focused on automation, audit effectiveness, operational efficiency, quality controls, standardization, and reduction of manual reconciliation risk.
• Identify opportunities to improve Healthcare data QA processes, data governance practices, vendor accountability, production monitoring, and operational transparency.
• Perform other duties as assigned.

Qualifications

• Bachelor's degree in business administration, Healthcare Administration, Information Systems, Data Analytics, Finance, or related field; or equivalent work experience.
• 10+ years of experience in healthcare claims, pharmacy operations, PBM data QA, healthcare data analysis, auditing, reconciliation, benefit administration, or partner interface support.
• Hands-on knowledge of inbound and outbound healthcare data transactions and file exchanges, including 834, 837, 270, 271, 276 and 277 transaction types.
• Strong working knowledge of pharmacy claims operations, pharmacy benefit administration, PBM workflows, claims adjudication concepts, accumulator processes, and pharmacy data reconciliation.
• Experience working with pharmacy claims data, accumulators, PBM reporting, or healthcare data feeds.
• Experience managing and leading 10+ onshore and offshore resources.
• Demonstrated leadership and coaching experience, including mentoring team members, setting priorities, managing workload distribution, and developing team performance.
• Experience leading data reconciliation, audit controls, issue resolution, and root cause analysis.
• Experience coordinating cross-functional work with business, technical, vendor, and operational teams.
• Technical proficiency in SQL queries, data analysis, source-to-target validation, data mapping, and record-level reconciliation to support healthcare data quality and root cause analysis.
• Experience monitoring SFTP file exchanges, automated data feeds, missing or delayed files, transmission failures, and vendor-related data exchange issues.
• Ability to develop and use data quality controls, exception reports, dashboards, and KPI reporting through tools such as Excel, Power BI, SQL, or similar reporting platforms.
• Prior experience creating reports, exception tracking, process documentation, or executive-level status updates.

Requirements

• Advanced degree or certification in healthcare administration, data analytics, process improvement, or related discipline preferred.
• Experience working directly with healthcare partner interfaces, PBMs and pharmacy vendors, including data exchange validation, operational issue resolution, and vendor accountability.
• Experience supporting healthcare data integrations, EDI transactions, SFTP file feeds, or automated data exchange processes.
• Experience with SQL, Power BI, data analytics tools, or reporting platforms.
• Familiarity with GBAS, VBA, or similar healthcare claims platforms.
• Knowledge of pharmacy benefit administration, accumulator management, and claims adjudication.
• Prior experience supervising analysts, leading distributed teams, managing offshore delivery, or overseeing operational workflows across multiple resources.
• Experience in process improvement, production monitoring, audit control design, or vendor performance management.

Benefits

• 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

Company Description

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.