Role Description

At UST, we help the world’s best organizations grow and succeed through transformation. Bringing together the right talent, tools, and ideas, we work with our client to co-create lasting change. Together, with over 30,000 employees in 30+ countries, we build for boundless impact—touching billions of lives in the process. Visit us at .

Summary

UST is looking for….

Claims Lead Role Summary We are seeking a Claims Lead to manage Facets-based claims operations for a US healthcare payer environment with preferred exposure to Claim workflows, BlueCard/shared administration, payment integrity controls, and claims governance. The role will own delivery, escalations, queue management, staff coaching, and SLA adherence.

Key Responsibilities Operations Management

- Own overall claims delivery within the Facets adjudication workplace, including workflow orchestration and execution oversight
- Manage daily production, work allocation, queue balancing, and operational throughput
- Drive consistency in claim processing across complexity segments, ensuring adherence to defined productivity benchmarks
- Maintain control over inventory health, aging, and throughput across multiple work queues Escalation / Functional Oversight
- Serve as the primary functional lead for Facets claims processing, spanning across Claims adjudication workflows, Benefit validation and pricing execution, Member and provider data dependencies.
- Drive resolution of complex claim scenarios involving Pricing discrepancies (fee schedule, case rate, institutional pricing logic), Benefits interpretation and configuration dependencies,



Retro eligibility and adjusted claims.
- Ensure alignment with Facets configurations, edits, and system-driven outcomes influencing claim disposition Governance / Quality
- Ensure adherence to coding standards, payment policies, payer edits, and payment integrity expectations.
- Lead quality governance through Calibration sessions, Audit reviews and validation, Root cause analysis and defect prevention to improve first-pass accuracy and reduce rework.
- Ensure adherence to defined accuracy standards across Financial outcomes, Payment correctness, Processing compliance
- Lead quality governance through Calibration sessions, Audit reviews and validation, Root cause analysis and defect prevention
- Address systemic error drivers linked to Pricing logic, Configuration gaps, Eligibility or provider data issues Mandatory Skills & Competencies
- Strong expertise in Facets claims adjudication and workflow management
- Deep understanding of claims lifecycle (intake to adjudication to adjustment), Benefits, pricing, and payment policies, System edits, pend management, and resolution workflows.
- Ability to manage complex, exception-driven claims environments
- Strong leadership across offshore delivery models, SLA-driven operations,



Stakeholder engagement and governance Qualifications
- Graduate (Mandatory).
- 8+ years of experience in US Healthcare Claims Operations.
- Minimum 2+ years in Team Lead / Operations Lead capacity.
- Strong Facets expertise required; Blue plan experience preferred..

Humility We will listen, learn, be empathetic and help selflessly in our interactions with everyone.

Humanity Through business, we will better the lives of those less fortunate than ourselves.

Integrity We honour our commitments and act with responsibility in all our relationships.

Equal Employment Opportunity Statement UST is an Equal Opportunity Employer. We believe that no one should be discriminated against because of their differences, such as age, disability, ethnicity, gender, gender identity and expression, religion, or sexual orientation. All employment decisions shall be made without regard to age, race, creed, colour, religion, sex, national origin, ancestry, disability status, veteran status, sexual orientation, gender identity or expression, genetic information, marital status, citizenship status or any other basis as protected by federal, state, or local law. UST reserves the right to periodically redefine your roles and responsibilities based on the requirements of the organization and/or your performance.

- To support and promote the values of UST.
- Comply with all Company policies and procedures

Skills FACETS, Claims Management, Stakeholder Management, Service Level Management

Skills

FACETS, Claims Management, Stakeholder Management, Service Level Management

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