JobsifyAISign in
Back to Jobs

Lead I - BPM- Claim

Multiple location · Remote Full-time 5-7 B.Tech / B.E. / MCA / BCA / M.Sc. IT / B.Sc. IT Direct Client hiring Posted 5 days ago💰 Not disclosed

Must Have Skills

FACETS | Claims Management | US Healthcare | Healthcare Systems | Benefits Administration | Claims Adjudication | Claims Pricing | Payment Policies | Pend Management | Payment Integrity | BPM | Operations Management | SLA | Quality Management | Process Improvement | BlueCard

Preferred Skills

Blue Plan / BlueCard experience Shared Administration experience Payment Integrity / Payment Accuracy Facets configuration exposure Healthcare payer operations Claims governance and audit experience

Job Summary

We are looking for an experienced Claims Lead – BPM to manage Facets-based claims operations within a Business Process Management (BPM) environment supporting a US healthcare payer.

The role will be responsible for end-to-end claims process delivery, operational governance, escalation management, workforce planning, quality management, SLA adherence, and continuous process improvement. Strong expertise in Facets Claims is mandatory, with exposure to BlueCard/shared administration, payment integrity, and claims governance preferred.

Multiple location : Bangalore , Trivandrum, Hyderabad, Chennai

Key Responsibilities

🔹 Claims Operations Management

  • Manage end-to-end claims operations within the Facets adjudication environment.
  • Oversee claims workflow execution, daily production, work allocation, queue balancing, and operational throughput.
  • Ensure consistent claims processing across different complexity levels.
  • Monitor inventory health, aging, throughput, productivity, and work-queue performance.
  • Track and manage operational KPIs, SLAs, and performance metrics.

🔹 Functional & Escalation Management

  • Act as the functional lead for Facets Claims processing.

  • Oversee Claims Adjudication, Benefits validation, Pricing, and Member/Provider data dependencies.

  • Handle complex claims involving:

  • Fee schedules

  • Case rates

  • Institutional pricing

  • Benefit interpretation

  • Retro eligibility

  • Adjusted claims

  • Pricing discrepancies

  • Analyze system edits, Facets configurations, and system-driven claim outcomes.

  • Lead escalations and coordinate with relevant stakeholders for timely resolution.

🔹 Governance & Quality Management

  • Ensure adherence to coding standards, payment policies, payer edits, and payment integrity requirements.
  • Drive quality governance through calibration sessions, audits, validation, RCA, and defect-prevention initiatives.
  • Maintain required accuracy standards for financial outcomes, payment correctness, and claims processing.
  • Identify systemic issues related to pricing logic, configuration, eligibility, and provider data.
  • Drive corrective and preventive actions to minimize errors and rework.

🔹 Process Improvement

  • Identify process gaps and operational bottlenecks.

  • Drive continuous improvement initiatives to improve:

  • First-pass accuracy

  • Processing efficiency

  • Productivity

  • Quality

  • SLA performance

  • Customer/business outcomes

  • Implement process optimization and operational excellence initiatives within the BPM environment.

🔹 Team & Stakeholder Management

  • Lead and manage claims operations teams in an offshore/BPM delivery environment.
  • Plan workforce requirements, resource allocation, and capacity.
  • Collaborate with business, technology, quality, and other stakeholders.
  • Provide regular operational updates, performance reporting, and escalation management.

Mandatory Skills & Competencies

  • Strong expertise in Facets Claims Adjudication
  • Claims Management / Claims Operations
  • Strong understanding of the US Healthcare Claims lifecycle
  • Benefits Administration
  • Claims Pricing and Payment Policies
  • System Edits and Pend Management
  • Claims Adjustment and Resolution Workflows
  • Business Process Management (BPM)
  • Operational Governance & Quality Management
  • SLA/KPI-driven operations
  • Process Optimization & Continuous Improvement
  • Strong stakeholder and escalation management
  • Experience managing offshore/BPM delivery operations
  • Strong analytical, problem-solving, leadership, and communication skills

Preferred Skills

  • Blue Plan / BlueCard experience
  • Shared Administration experience
  • Payment Integrity / Payment Accuracy
  • Facets configuration exposure
  • Healthcare payer operations
  • Claims governance and audit experience

Qualifications

  • B.Tech / B.E. / MCA / BCA / M.Sc. IT / B.Sc. IT
  • Graduate qualification is mandatory.
  • 8+ years of experience in US Healthcare Claims Operations
  • Minimum 2+ years of experience in Team Lead / Operations Lead capacity
  • Strong hands-on Facets Claims experience is mandatory.
  • Experience managing BPM operations and process improvement initiatives.

Screening questions

Asked of every applicant before they can apply.

Apply for this role