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 workplace 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.

📌 Business Process Management Consultant (Bengaluru)
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📍 Bengaluru