Senior Process & Performance Optimization Specialist

EmblemHealth; New York (NY); On-site; USD 68,000 - 119,000; Full time

Job summary

EmblemHealth in New York is seeking an experienced Operations Improvement Lead to drive end-to-end initiatives across Claims, Enrollment, Call Center, and more. You will translate business needs into structured work, partner with IT and vendors, and deliver measurable outcomes through data-driven analysis and stakeholder collaboration.

The role emphasizes autonomous execution, detailed planning, and ongoing optimization of end-to-end workflows to support business priorities with minimal

Qualifications

• Bachelor's Degree required.
• 4-6+ years of healthcare payer operations or management consulting experience.
• Experience leading process improvement initiatives across cross-functional teams.
• Proficiency with MS Office and process mapping tools; Jira/Azure DevOps a plus.

Responsibilities

• Execute and drive initiatives across Operations from intake to completion.
• Define scope, objectives, milestones, deliverables, risks, and dependencies.
• Develop execution plans using Excel, MS Project, Smartsheet, or Agile tools.
• Engage Operations, IT, vendors, offshore teams, and partners.
• Lead sessions to align objectives and resolve issues.
• Identify risks and drive resolution with stakeholders.
• Ensure accountability and measurable operational impact.
• Translate operational needs into requirements and user stories; support UAT and testing.
• Monitor performance and adoption; provide data-driven insights.

Skills

Data analysis

Project management

Stakeholder engagement

Process improvement

Operations management

Education

Bachelor's Degree

Tools

MS Office

Visio

Jira

Azure DevOps

Job description

Summary of Position

• Responsible for executing and driving initiatives and ongoing optimization efforts that improve performance across end-to-end Operations, including Claims, Provider Operations, Compliance, Grievance & Appeals, Enrollment & Billing, and Call Center functions with minimal oversight.
• Acts as a cross-functional execution lead who identifies operational challenges and improvement opportunities through data analysis and stakeholder engagement, translates business needs into structured work efforts, and drives initiatives through completion.
• Partners with Operations, IT, vendors, offshore teams, and upstream/downstream stakeholders to ensure that process improvements, system enhancements, and workflow changes are effectively implemented, adopted, and deliver measurable operational outcomes.
• Operates with a high degree of autonomy, managing work efforts from intake through execution while ensuring alignment with business priorities.

Principal Accountabilities

• Independently drive execution of initiatives and work efforts from intake through completion across Operations
• Define and structure assigned work efforts, including scope, objectives, milestones, deliverables, risks, and dependencies
• Develop and maintain detailed execution plans using tools such as Excel, MS Project, Smartsheet, or Agile platforms (Jira/Azure DevOps)
• Identify and engage appropriate stakeholders across Operations, IT, vendors, offshore teams, and upstream/downstream partners
• Lead working sessions to align objectives, progress, and issue resolution
• Proactively identify execution risks, blockers, and gaps; drive resolution through direct engagement and follow-up
• Ensure clear ownership and accountability for action items and deliverables across stakeholders.
• Escalate issues with context, data, and recommended solutions to leadership when needed
• Validate that initiatives are completed with measurable operational impact and aligned to defined success criteria
• Identify and drive improvements across end-to-end operational workflows spanning multiple business areas.
• Conduct current-state assessments through stakeholder interviews, workflow walkthroughs, and job shadowing
• Analyze processes across functional boundaries (e.g., Enrollment Claims Appeals Call Center)
• Develop detailed process maps including decision points, handoffs, rework loops, and system interactions
• Quantify inefficiencies using data such as cycle time, backlog, error/rework rates, and productivity metrics
• Perform root cause analysis across people, process, and technology dimensions.
• Identify and define improvement opportunities that are practical, scalable, and aligned to business constraints.
• Evaluate upstream and downstream impacts of proposed changes
• Drive implementation of process improvements, including stakeholder alignment and operational readiness.
• Validate effectiveness of changes post-implementation and adjust as needed.
• Translate operational needs into clearly defined requirements and support successful delivery of system and workflow changes.
• Gather and synthesize business requirements through structured stakeholder engagement
• Translate needs into user stories, business requirements, acceptance criteria, and process workflows, ensuring requirements reflect operational realities, dependencies, and success measures.
• Partner with IT and product teams to refine backlog items and clarify priorities.
• Develop test scenarios and lead coordination of User Acceptance Testing (UAT)
• Track defects, ensure resolution, and validate system functionality.
• Confirm alignment between delivered solutions and intended operational outcomes.
• Partner with stakeholders to ensure readiness for implementation.
• Support data-driven decision-making and monitor operational performance and initiative outcomes.
• Extract, compile, and analyze data across multiple operational areas (Claims, Call Center, Enrollment, etc.).
• Track key performance indicators, including but not limited to: Inventory and backlog levels, Turnaround times, First-pass yield / accuracy rates, Productivity and utilization metrics.
• Develop working dashboards, scorecards, and tracking tools using Excel or Power BI.
• Identify trends, performance gaps, and emerging risks.
• Provide actionable, data-driven insights and recommendations to stakeholders and leadership.
• Identify and support implementation of automation and efficiency opportunities across Operations.
• Identify repetitive, manual, or high-volume processes suitable for automation (RPA, AI-enabled solutions, workflow tools).
• Document use cases, including current-state effort, expected benefits, and operational impact.
• Evaluate feasibility and prioritize opportunities based on value and complexity.
• Participate in testing, validation, and rollout of automated solutions.
• Monitor early performance and track realization of expected benefits.
• Identify and address issues impacting performance or adoption.
• Ensure effective rollout, adoption, and sustainability of process and system changes by developing and executing practical rollout plans aligned with operational workflows and constraints.
• Create clear and usable documentation, including job aids, process guides, and training materials.
• Support training sessions, stakeholder walkthroughs, and working sessions.
• Engage operations teams, vendors, and offshore partners to ensure understanding and readiness.
• Gather feedback from end users and identify adoption challenges.
• Identify risks related to change adoption (e.g., workarounds, resistance, knowledge gaps).
• Drive or recommend corrective actions to ensure sustained adoption and performance.
• Drive alignment and communication across stakeholders and provide visibility to leadership.
• Identify and engage relevant stakeholders across Operations, IT, vendors, and partner teams.
• Facilitate working sessions, discussions, and problem-solving forums.
• Develop structured materials and presentations for leadership updates.
• Communicate initiative progress, risks, issues, and outcomes clearly and concisely.
• Present findings, insights, and recommendations to Director- and SVP-level stakeholders as needed.
• Ensure alignment across stakeholders on priorities, expectations, and outcomes.

Qualifications

Education, Training, Licenses, Certifications

• Bachelor's Degree required

Relevant Work Experience, Knowledge, Skills, and Abilities

• 4-6+ years of relevant experience in healthcare payer operations (Claims strongly preferred) or management consulting with a focus on operational performance improvement required
• Experience leading or independently executing process improvement initiatives, operational optimization efforts, or system implementations required
• Experience working across cross-functional teams, including Operations and Technology partners required
• Demonstrated ability to operate independently, manage multiple work efforts, and drive initiatives to completion with minimal oversight required
• Strong understanding of end-to-end healthcare operations workflows, including upstream & downstream dependencies required
• Experience working with vendors and/or offshore teams in an operational or project capacity required
• Strong analytical and problem-solving skills, including root cause analysis and data interpretation required
• Proficiency with MS Office (Excel, PowerPoint, MS Project, Teams, Outlook) and process mapping tools (e.g., Visio) required
• Experience with Agile tools such as Jira or Azure DevOps required
• Strong written and verbal communication skills, including development of structured presentations and materials for leadership audiences required
• Experience with automation, AI-enabled solutions, or workflow optimization tools preferred

Additional Information

Hiring Range: $68,040-$118,800