Lead I - BPM- Claim

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.