Business Process Management Consultant

Location: Trivandrum / Bengaluru / Chennai

Experience: 8+ years in US Healthcare Claims Operations, including 2+ years as Team Lead/Operations Lead

Education: Graduate (mandatory); BTech/MCA/BCA/MSc IT/BSc IT preferred

Role Summary

Seeking a Claims Lead to manage Facets-based claims operations in a BPM environment supporting a US healthcare payer. Responsible for end-to-end delivery, operational governance, escalation management, workforce planning, quality oversight, process optimization, and SLA adherence.

Key Responsibilities

• Own end-to-end claims delivery within the Facets adjudication environment, including workflow orchestration and execution oversight.
• Manage daily production, work allocation, queue balancing, and throughput.
• Ensure consistent claims processing across complexity segments and adherence to productivity benchmarks.
• Monitor inventory health, aging, throughput, and KPIs/SLAs across multiple work queues.
• Serve as functional lead for Facets claims processing: adjudication workflows, benefit validation, pricing execution, and member/provider data dependencies.
• Resolve complex claims scenarios: pricing discrepancies (fee schedule, case rate, institutional pricing), benefits interpretation/configuration, retro eligibility, and adjusted claims.
• Ensure alignment with Facets configurations, edits, and system-driven claim dispositions.
• Identify process gaps and implement corrective actions with stakeholders.
• Ensure adherence to coding standards, payment policies, payer edits, payment integrity expectations, and BPM governance frameworks.
• Lead quality governance: calibration sessions, audit reviews, root cause analysis, and defect prevention.
• Address systemic errors linked to pricing logic, configuration gaps, eligibility, or provider data.
• Drive continuous improvement to enhance efficiency, first-pass accuracy, and reduce rework.

Required Skills

• Strong expertise in Facets claims adjudication and workflow management.
• Deep understanding of claims lifecycle (intake to adjudication to adjustment), benefits, pricing, payment policies, system edits, pend management, and resolution workflows.
• Knowledge of BPM, operational governance, process optimization, and quality management.
• Experience in SLA-driven operations, stakeholder management, process governance, and offshore delivery models.
• Strong analytical, problem-solving, leadership, and communication skills.
• Facets expertise required; Blue Plan experience preferred.

Preferred Exposure

• Claims workflows, BlueCard/shared administration, payment integrity controls, and claims governance.