Healthplan Claims Advisor- REMOTE

Sierra Solutions; New York (NY); Remote; USD 110,000 - 160,000; Full time

Job summary

Sierra Solutions is seeking a seasoned Consulting Lead to oversee the Claims Workstream for a major BPaaS implementation for a health plan client. The ideal candidate will possess extensive experience in health plan operations and claims management, providing strategic guidance and ensuring alignment with business goals. This contract position is suited for a mid-senior level professional looking to drive transformational initiatives within the health care sector.

Qualifications

• 10+ years of experience in health plan operations with focus on claims.
• Experience in consulting on large-scale health plan transformations.
• Familiarity with major claims platforms.

Responsibilities

• Guide end-to-end claims workstream strategy and execution.
• Act as executive advisor, providing strategic guidance.
• Ensure future-state claims operating model aligns with compliance.

Skills

Claims adjudication

Denials management

Appeals & grievances

Stakeholder management

Analytical skills

Communication skills

Organizational skills

Process optimization

Education

10+ years experience in health plan operations

Strong focus on claims processing

Experience in consulting roles

Tools

HealthRules Payer

Facets

Job description

We are seeking a seasoned Consulting Lead to serve as both an Executive Advisor and Workstream Lead for the Claims Workstream of a major Business Process as a Service (BPaaS) implementation for a health plan client. The ideal candidate brings deep subject matter expertise across claims adjudication, denials, appeals, and grievances, along with extensive experience leading health plan operational transformations and working with third-party BPaaS vendors. Familiarity with HealthRules Payer, Facets, and other claims platforms is highly preferred.

In this role, you will guide the end-to-end claims workstream strategy, execution, and stakeholder alignment, ensuring the workstream aligns with business goals, compliance standards, and operational efficiency targets.

Primary Responsibilities

• Act as executive advisor to client leadership, providing strategic guidance on claims operations, denials, appeals, and grievances in the context of a BPaaS delivery model.
• Lead the claims workstream within a large-scale BPaaS transformation program from planning through implementation and stabilization.
• Translate business goals into actionable implementation plans, deliverables, and milestones specific to claims-related functions.
• Oversee coordination between the health plan client and the BPaaS vendor to ensure clear requirements, appropriate process redesign, and successful execution of transition activities.
• Serve as escalation point for claims-related issues, ensuring resolution through collaboration with technical, operational, and vendor teams.
• Ensure that the future-state claims operating model supports regulatory requirements, contractual SLAs, and provider/member experience expectations.
• Provide subject matter expertise on claims adjudication logic, denial management protocols, appeal and grievance workflows, and integration with related functions (e.g., UM, provider data, eligibility).
• Support testing, validation, and go-live readiness activities, ensuring the claims workstream is fully operational and integrated with upstream/downstream systems.
• Identify risks, interdependencies, and opportunities for process optimization across the claims value chain.
• Contribute to executive steering committee meetings and provide reporting and insights on progress, risks, and performance metrics.

Education and Experience

• 10+ years of experience in health plan operations with a strong focus on claims processing, denials management, and appeals & grievances.
• Demonstrated leadership in consulting or advisory roles on large-scale health plan transformation initiatives, including BPaaS or outsourcing engagements.
• Experience acting as a strategic liaison between payers and third-party BPaaS vendors or BPO providers.
• In-depth understanding of claims operations including benefit configuration, pricing methodologies, payment integrity, and audit functions.
• Familiarity with major claims platforms such as HealthRules Payer and Facets (experience with both preferred).
• Excellent stakeholder management skills, including experience working with C-suite executives and program sponsors.
• Proven ability to drive cross-functional collaboration and lead through influence in matrixed environments.
• Strong analytical, communication, and organizational skills.

Seniority level

Mid-Senior level

Employment type

Contract

Job function

Health Care Provider and Information Technology

Industries

Wellness and Fitness Services, Hospitals and Health Care, and IT Services and IT Consulting