Medical Claims Lead (Facets Exp Required)

UST; Taguig; On-site; PHP 1,800,000 - 3,000,000; Full time

Job summary

UST is seeking a Claims Lead to oversee end-to-end claims operations in a BPM environment for a U.S. healthcare payer. You will manage daily production, governance, and quality, driving improvements in accuracy and SLA compliance across multiple queues.

The role requires deep expertise in Facets claims adjudication, claims lifecycle, and pricing/payments policies, with strong leadership and offshore delivery experience. Graduate degree required.

Qualifications

• Graduate degree required.
• 8+ years of experience in U.S. healthcare claims operations.
• Minimum 2 years in a team lead role or similar capacity.
• Strong Facets expertise is required.
• Experience with offshore delivery models is an advantage.

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.
• Serve as the functional lead for claims adjudication and workflow management.
• Resolve complex claims involving pricing discrepancies, benefit interpretation, retro eligibility, and adjusted processing.
• Ensure alignment with Facets configurations, edits, and system-driven outcomes.
• Partner with stakeholders to identify gaps and implement corrective actions.
• 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 to enhance first-pass accuracy and reduce rework.

Skills

Facets adjudication

Workflow management

SLA management

Leadership

Communication

Offshore delivery

Pricing methodologies

Education

Graduate degree required

Tools

Facets

Job description

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 experience in a Team Lead role or similar capacity
• Strong Facets expertise is required
• Blue Plan/BlueCard experience an advantage but not required
• Experience in managing day-to-day operations, operational excellence initiatives, and process improvement programs

Successful candidates will be asked to provide NBI, educational and former employment docs