Claims Lead I - BPM

UST USource; Pateros; On-site; PHP 4,711,000 - 6,595,000; Full time

Job summary

UST USource is seeking a Claims Lead for BPM (Facets Claims Operations) to oversee end-to-end claims delivery within a Facets environment. The role emphasizes governance, workforce management, quality oversight, and SLA adherence across multiple queues to drive efficiency and accuracy.

The ideal candidate will have a graduate degree and 8+ years in U.S. Healthcare Claims Operations, with proven leadership and offshore delivery experience.

Qualifications

• Strong expertise in Facets claims adjudication and workflow management.
• Deep understanding of claims lifecycle, benefits administration, pricing methodologies, and payment policies.
• Experience managing SLA-driven operations and offshore delivery models.

Responsibilities

• Lead end-to-end claims delivery within the Facets adjudication environment.
• Manage daily production, work allocation, workload balancing, and throughput.
• Monitor inventory, aging, productivity, and operational performance across queues.
• Ensure adherence to KPIs, SLAs, and productivity targets.
• Drive consistency and efficiency in claims processing activities.

Skills

Facets adjudication

Workflow management

SLA governance

Leadership

Communication

Education

Graduate degree

Job description

Claims Lead – BPM (Facets Claims Operations)

Role Summary

The Claims Lead will oversee end-to-end claims operations within a Business Process Management (BPM) environment supporting a U.S. healthcare payer. This role is responsible for operational delivery, governance, workforce management, quality oversight, escalation management, process optimization, and SLA compliance. The ideal candidate will have strong expertise in Facets claims adjudication, healthcare claims operations, and operational leadership.

Key Responsibilities

Operations Management

• Lead end-to-end claims delivery within the Facets adjudication environment.
• Manage daily production, work allocation, workload balancing, and throughput.
• Monitor inventory, aging, productivity, and operational performance across multiple queues.
• Ensure adherence to KPIs, SLAs, and productivity targets.
• Drive consistency and efficiency in claims processing activities.

Escalation & Functional Oversight

• Serve as the functional lead for claims adjudication and workflow management.
• Resolve complex claims involving:
  • Pricing discrepancies
  • Benefit interpretation issues
  • Retro eligibility scenarios
  • Adjusted claims processing
• Ensure alignment with Facets configurations, edits, and system-driven outcomes.
• Partner with stakeholders to identify gaps and implement corrective actions.

Governance & Quality

• Ensure compliance with coding standards, payment policies, payer edits, and governance requirements.
• Lead audit reviews, calibration sessions, root cause analysis, and defect prevention initiatives.
• Monitor accuracy across payment outcomes, compliance measures, and operational metrics.
• Address systemic issues related to pricing, eligibility, configuration, and provider data.
• Drive continuous improvement initiatives to enhance first-pass accuracy and reduce rework.

Mandatory Skills & Competencies

• Strong expertise in Facets claims adjudication and workflow management.
• Deep understanding of:
  • Claims lifecycle (intake, adjudication, adjustments)
  • Benefits administration
  • Pricing methodologies
  • Payment policies
  • System edits and pend management
  • Claims resolution workflows
• Strong knowledge of BPM operations, governance, process improvement, and quality management.
• Experience managing complex, exception-based claims environments.
• Proven ability to manage SLA-driven operations, stakeholder relationships, and offshore delivery models.
• Strong leadership, analytical, problem-solving, and communication skills.

Qualifications

• Graduate degree required
• 8+ years of experience in U.S. Healthcare Claims Operations
• Minimum 2+ years of experience in a Team Lead or Operations Lead role
• Strong Facets expertise is required
• Blue Plan/BlueCard experience an advantage
• Experience in managing day-to-day operations, operational excellence initiatives, and process improvement programs