Director of Digital Transformation at Imperial Management Administrators Services Inc – Pasadena, California

Director of Digital Transformation

Position Summary

The Director of Digital Transformation is responsible for leading enterprise technology modernization and business process re-engineering across Medicare Advantage and ACA lines of business. This role partners directly with Operations, Risk Adjustment, Quality, Finance, Network, Compliance, and IT to design, implement, and optimize scalable digital and data-driven solutions.

The position is execution-focused and requires strong systems architecture knowledge, workflow automation expertise, and health plan core administration experience.

The role will report to the CEO with a dotted line to the VP of IT. The role will work closely with other operational departments including Claims, enrollment, billing, risk adjustment, quality, finance, compliance, network and vendor platforms to lead workflow automation. This role is intended to elevate systems modernization as and enterprise priority, facilitate stronger cross-functionality authority and reduce operational silos. The role will own core health plan systems, reduce manual processes, strengthen regulatory readiness, improve risk adjustment integrity, support scalable membership growth.

Job Duties

1. Core System Modernization

• Lead optimization and configuration of core administration systems (claims, enrollment, billing, care management).

• Oversee system integrations between:

o Claims platforms

o CRM systems

o Risk adjustment tools

o Data warehouse/BI environments

o Design scalable system architecture to support:

o Medicare Advantage

o ACA Marketplace enrollment and reconciliation

• Reduce system fragmentation and manual workarounds.

• Map systems and identify opportunities for work flow automation

o Automate discrepancy reports.

o Improve APTC reconciliation workflow.

o Implement real-time 834 validation.

o 20% reduction in manual enrollment touches.

• Workflow Automation

• Deploy RPA for:

 Prior authorization intake

 Appeals tracking

 Claims exception routing

 Reduce manual queue volume.

• Interoperability Implementation

 Deploy or improve FHIR APIs.

 Standardize provider data feeds.

 Improve supplemental data ingestion.

2. Business Process Engineering

• Map and re-engineer workflows across:

• Enrollment & eligibility

• Premium billing (including APTC reconciliation)

• Claims adjudication

• Prior authorization

• Appeals & grievances

• Identify automation opportunities using:

• RPA

• API integrations

• Workflow engines

• Implement measurable process improvements (cycle time reduction, error rate reduction).

3. Data Architecture & Risk Adjustment Enablement

• Oversee integration of CMS-HCC and HHS-HCC risk adjustment tools into operational workflows.

• Ensure encounter data and EDI submissions are:

• Accurate

• Timely

• Audit-ready

• Partner with actuarial and finance teams to ensure RAF/HHS-HCC data integrity.

• Improve clinical data ingestion (EHR feeds, FHIR APIs, supplemental data).

4. Interoperability & API Strategy

• Implement FHIR-based data exchange frameworks.

• Oversee 837, 835, 834, 820, and other EDI transaction optimization.

• Ensure compliance with CMS interoperability mandates.

• Establish real-time data exchange capabilities between internal systems and vendors.

5. Quality & Regulatory Systems Support

• Support technical infrastructure for:

• Star Ratings (MA)

• QRS (ACA)

• HEDIS reporting

• Improve data aggregation and gap closure reporting accuracy.

• Ensure system controls support audit readiness (RADV, marketplace audits).

6. Analytics & Automation

• Oversee development of operational dashboards for:

a. Utilization management

b. Claims turnaround time

c. Care gap closure

d. Risk capture rates

• Lead implementation of predictive modeling tools in collaboration with analytics teams.

• Deploy automation solutions to reduce administrative burden.

7. Vendor & Platform Governance

• Manage technical relationships with:

• Core admin vendors

• Risk adjustment vendors

• Interoperability vendors

• Lead system configuration governance.

• Ensure SLA adherence and performance optimization.

8. IT Collaboration & Infrastructure Alignment

• Partner with CIO/IT leadership on:

1. Cybersecurity alignment

2. Cloud strategy

3. Data governance

4. Disaster recovery planning

• Ensure system scalability for membership growth.

Required Experience

• 8–12+ years in health plan IT, digital operations, or systems transformation.

• Direct experience with:

a. Core health plan administration platforms

b. EDI transactions (837, 834, etc.)

c. Risk adjustment data flows (CMS-HCC & HHS-HCC)

d. ACA enrollment and premium reconciliation systems

• Strong understanding of:

• Medicare Advantage operations

• ACA Marketplace operations

• Health plan compliance infrastructure

• Experience leading cross-functional technical implementations.

Key Competencies

• Systems architecture thinking

• Workflow redesign expertise

• API and interoperability knowledge

• Data governance & analytics alignment

• Operational cost reduction focus

• Execution-oriented leadership