Claims Operations Facets Lead

1 Experience 10+ Years in Healthcare Payer Operations, BPM Operations, and FACETS Claims Processing

Lead the end-to-end transition and operational delivery of FACETS Claims Operations, ensuring successful knowledge acquisition, operational readiness, stabilization, and seamless transition to steady-state support.

Act as the primary client-facing lead and trusted advisor for Claims Operations, managing executive stakeholder relationships, governance forums, risk reviews, and operational decision-making. Partner with client SMEs and business leaders to assess current-state operations, define future-state operating models, and establish service delivery frameworks. Drive transition planning, knowledge transfer execution, readiness assessments, and operational acceptance activities to ensure a successful handoff to delivery teams.

Oversee FACETS claims adjudication operations, ensuring adherence to productivity, quality, accuracy, turnaround time, and SLA commitments.

Establish governance processes, performance metrics, reporting dashboards, and controls to monitor operational performance and deliver continuous visibility to stakeholders. Identify operational risks, process gaps, dependencies, and improvement opportunities, implementing mitigation plans and corrective actions to ensure delivery stability. Collaborate with cross-functional teams including Enrollment, Provider Operations, Configuration, Application Support, and Technology teams to drive end-to-end process effectiveness. Lead continuous improvement, automation, and transformation initiatives to enhance operational efficiency, quality, customer experience, and business outcomes.

Provide leadership, coaching, and direction to onshore and offshore operations teams, fostering a culture of accountability, collaboration, and operational excellence. Support workforce planning, capacity management, forecasting, and resource optimization to align with client demand and business objectives. Ensure compliance with healthcare payer regulations, client policies, audit requirements, and operational governance standards.

Lead Healthcare BPM delivery and operations management, ensuring SLA adherence, productivity targets, quality performance, operational governance, and continuous process improvement. Drive BPM transformation initiatives, process standardization, automation opportunities, operational excellence programs, and service delivery optimization across healthcare payer operations. Manage Healthcare BPM/BPO delivery teams, stakeholder governance, performance management, and operational reviews to achieve business outcomes and customer satisfaction goals.

10+ years of Healthcare Payer Operations and BPM/BPO Operations experience with deep expertise in FACETS Claims Processing and Adjudication. Proven experience leading large-scale transition, transformation, and managed services engagements. Strong understanding of Commercial, Medicare, Medicaid, and Government Programs claims operations. Demonstrated success managing client relationships, operational governance, service delivery, and cross-functional teams. Experience managing large-scale onsite/offshore BPM delivery teams. Strong knowledge of SLA management, productivity management, operational governance, workforce management, and continuous improvement methodologies.

Excellent communication, stakeholder management, and leadership skills. Preferred Qualifications Experience leading Healthcare BPM transformation programs. Exposure to Lean Six Sigma, Process Excellence, Automation, and AI-enabled operational transformation initiatives. Knowledge of FACETS and Healthcare Payer operational workflows across Claims, Enrollment, Provider, Billing, and Configuration functions. Success Measures SLA/KPI Compliance