Claims Lead I - BPM

UST; Taguig; On-site; PHP 7,538,000 - 10,050,000; Full time

Job summary

UST is seeking a Claims Lead for BPM (Facets Claims Operations) to oversee end-to-end claims delivery within a Facets environment for a U.S. healthcare payer. The role focuses on governance, workforce management, quality oversight, escalation handling, and SLA compliance.

The ideal candidate has deep experience in claims lifecycle, benefits interpretation, pricing methodologies, and system edits, with 8+ years in U.S. Healthcare Claims Operations and at least 2 years in a lead capacity.

Qualifications

• Graduate degree required.
• 8+ years in U.S. Healthcare Claims Operations.
• Minimum 2+ years in a Team Lead or Operations Lead role.
• Strong Facets expertise required.
• Blue Plan/BlueCard experience is a plus.

Responsibilities

• Oversee end-to-end claims delivery within Facets adjudication environment.
• Manage daily production, work allocation, and throughput across queues.
• Ensure KPIs, SLAs, and productivity targets are met.
• Lead governance, quality, and defect prevention initiatives.
• Drive process optimization and first-pass accuracy improvements.

Skills

Facets adjudication

Workflow management

SLA management

Leadership

Analytical skills

Education

Graduate degree

Tools

Facets

Job description

• Retro eligibility scenarios

Role Description

Claims Lead – BPM (Facets Claims Operations)

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

Skills

FACETS, Claims Management, Stakeholder Management, Service Level Management