Lead I - BPM- Claim

About The Job:
Claims Lead - BPM

• We are seeking a Claims Lead 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 process delivery, operational governance, escalation management, workforce planning, quality oversight, process optimization, and SLA adherence, with preferred exposure to Claims workflows, BlueCard/shared administration, payment integrity controls, and claims governance.

Essential Job Functions:
Operations Management

• Own overall claims delivery within the Facets adjudication environment, including workflow orchestration and execution oversight.
• Manage daily production, work allocation, queue balancing, and operational throughput.
• Drive consistency in claims processing across complexity segments, ensuring adherence to defined productivity benchmarks.
• Maintain control over inventory health, aging, throughput, and operational performance across multiple work queues.
• Monitor process KPIs, SLAs, and operational metrics to ensure business objectives are achieved.

Escalation / Functional Oversight

• Serve as the primary functional lead for Facets claims processing, spanning Claims adjudication workflows, Benefit validation and pricing execution, and 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.
• Collaborate with stakeholders to identify process gaps and implement corrective actions.

Governance / Quality

• Ensure adherence to coding standards, payment policies, payer edits, payment integrity expectations, and BPM governance frameworks.
• Lead quality governance through calibration sessions, audit reviews and validation, root cause analysis, and defect prevention initiatives.
• Ensure adherence to defined accuracy standards across financial outcomes, payment correctness, processing compliance, and operational excellence metrics.
• Address systemic error drivers linked to pricing logic, configuration gaps, eligibility, or provider data issues.
• Drive continuous process improvement initiatives to enhance operational efficiency and first-pass accuracy while reducing rework.

Qualifications:
Mandatory Skills & Competencies

• 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.
• Strong knowledge of Business Process Management (BPM), operational governance, process optimization, and quality management practices.
• Ability to manage complex, exception-driven claims environments.
• Experience in SLA-driven operations, stakeholder management, process governance, and offshore delivery models.
• Strong analytical, problem-solving, leadership, and communication skills.

Education

• 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.
• Experience in managing BPM operations, operational excellence initiatives, and process improvement programs.
• BTech/ MCA/ BCA/Msc IT/Bsc IT

Required Skills:

• FACETS
• Claims Management
• Healthcare Systems
• Benefits Administration

How to Apply: Interested candidates are encouraged to respond/submit their updated resumes, and for additional job opportunities, please visitJobs In India – VARITE.

Unlock Rewards: Refer Candidates and Earn.

If you're not available or interested in this opportunity, please pass this along to anyone in your network who might be a good fit and interested in our open positions. VARITE offers a Candidate Referral program, where you'll receive a one-time referral bonus based on the following scale if the preferred candidate completes a three-month assignment with VARITE.

Experience Level Bonus Referral:

• 0-2 years - INR 5,000
• 2-6 years - INR 7,500
• 6+ years - INR 10,000

About VARITE: VARITE is a global staffing and IT consulting company providing technical consulting and team augmentation services to Fortune 500 Companies in USA, UK, CANADA and INDIA. VARITE is currently a primary and direct vendor to the leading corporations in the verticals of Networking, Cloud Infrastructure, Hardware and Software, Digital Marketing and Media Solutions, Clinical Diagnostics, Utilities, Gaming and Entertainment, and Financial Services.

Equal Opportunity Employer:

VARITE is an equal opportunity employer. We celebrate diversity and are committed to creating an inclusive environment for all employees. We do not discriminate based on race, color, religion, sex, sexual orientation, gender identity or expression, national origin, age, marital status, veteran status, or disability status