Manager I BPM - Claims Operations (FACETS) Lead

Manager I BPM - Claims Operations (FACETS) Lead Location: United States - Seattle, Washington (No Remote) Employment Type: Full-Time Experience: 10+ Years Open Positions: 1

Experience 10+ Years in Healthcare Payer Operations, BPM Operations, and FACETS Claims Processing Key Responsibilities Lead the end-to-end transition and operational delivery of FACETS Claims Operations, ensuring successful knowledge acquisition, operational readiness, stabilization, and seamless transition to steady-state support. Act as the primary client-facing lead and trusted advisor for Claims Operations, managing executive stakeholder relationships, governance forums, risk reviews, and operational decision-making. Partner with client SMEs and business leaders to assess current-state operations, define future-state operating models, and establish service delivery frameworks. Drive transition planning, knowledge transfer execution, readiness assessments, and operational acceptance activities to ensure a successful handoff to delivery teams. Oversee FACETS claims adjudication operations, ensuring adherence to productivity, quality, accuracy, turnaround time, and SLA commitments. Establish governance processes, performance metrics, reporting dashboards, and controls to monitor operational performance and deliver continuous visibility to stakeholders. Identify operational risks, process gaps, dependencies, and improvement opportunities, implementing mitigation plans and corrective actions to ensure delivery stability. Collaborate with cross-functional teams including Enrollment, Provider Operations, Configuration, Application Support, and Technology teams to drive end-to-end process effectiveness. Lead continuous improvement, automation, and transformation initiatives to enhance operational efficiency, quality, customer experience, and business outcomes. Provide leadership, coaching, and direction to onshore and offshore operations teams, fostering a culture of accountability, collaboration, and operational excellence. Support workforce planning, capacity management, forecasting, and resource optimization to align with client demand and business objectives. Ensure compliance with healthcare payer regulations, client policies, audit requirements, and operational governance standards. Lead Healthcare BPM delivery and operations management, ensuring SLA adherence, productivity targets, quality performance, operational governance, and continuous process improvement. Drive BPM transformation initiatives, process standardization, automation opportunities, operational excellence programs, and service delivery optimization across healthcare payer operations. Manage Healthcare BPM/BPO delivery teams, stakeholder governance, performance management, and operational reviews to achieve business outcomes and customer satisfaction goals. Required Qualifications 10+ years of Healthcare Payer Operations and BPM/BPO Operations experience with deep expertise in FACETS Claims Processing and Adjudication. Proven experience leading large-scale transition, transformation, and managed services engagements. Strong understanding of Commercial, Medicare, Medicaid, and Government Programs claims operations. Demonstrated success managing client relationships, operational governance, service delivery, and cross-functional teams. Experience managing large-scale onsite/offshore BPM delivery teams. Strong knowledge of SLA management, productivity management, operational governance, workforce management, and continuous improvement methodologies. Excellent communication, stakeholder management, and leadership skills. Preferred Qualifications Experience leading Healthcare BPM transformation programs. Exposure to Lean Six Sigma, Process Excellence, Automation, and AI-enabled operational transformation initiatives. Knowledge of FACETS and Healthcare Payer operational workflows across Claims, Enrollment, Provider, Billing, and Configuration functions. Success Measures SLA/KPI Compliance C.

Expectations from this role:
1. Works closely with the Manager/Group Manager to achieve quantitative and qualitative SLAs and KPIs for the team.
2. Focuses on planning and execution to ensure quality improvement, turnaround time and overall process efficiency.
3. Identifies process gaps and collaborates with the client to formulate solutions for the same.
4. Regularly interacts with the Quality team to ensure real time action in cases of quality defects.
5. Leads corrective and preventive action plans for various transactions and owns them.
6. Ensures that leads are informed on all process and business updates; and the relevant information is cascaded to associates in every team to ensure transparent communication.
7. Set clear team goals and transparent objectives on what the team is working towards to ensure clarity.Typical performance measures:
22. 100% Adherence to quality standards, process and SLA’s
23. Number of issues resolved and tasks completed
24. Number of non-compliance issues with respect to SOP
25. Zero/No Client Escalations
26. Percent of completion of all mandatory training requirements
27. Percent of QC and QA scores
28. RCA and Corrective Action Plans
29. Daily/weekly performance reporting
30. Number of high-quality RCA and QA output
31. Guides and mentors the junior associates.
32. Swift turnaround time for response and resolution
33. Update SOPs and job aids on a weekly basis
34. Delegate tasks and set deadlines for the teamPerformance Areas:
1. Operations: Ensure team handles the work received and adheres to SLAs
2. Quality: Responsible for creating quality plans and implementing quality management function
3. Communication:
• Responsible for reporting and communicating with client and internal team members.
• Communicates with clients daily and provides status update, obtains feedback and acts immediately on any issues highlighted.
• Provides status update to the respective stakeholders and within the team
• Shares performance reports to the client at the end of every month on team output and productivity.
4. Process/efficiency Improvement: Proactively identify opportunities to increase service levels and mitigate any issues in delivery within the function or across functions. Take accountability for overall productivity efforts within the function, including coordination of function specific tasks.
5. Training: On time completion of all mandatory training requirements of organization and customer. Provide on floor training and one on one mentorship for new joiners. Complete certification of respective career paths.
6. Performance Management: Update FAST Goals in NorthStar, track, report and seek continuous feedback from peers and manager. Set goals for team members and mentees and provide feedback.
7. Escalation: Escalate problems to appropriate individuals/support team based on established guidelines and procedures.
8. Monitoring: Monitors progress of requests for support and ensures users and other interested parties are kept informed.
9. Process Adherence: Thorough understanding of organization and customer defined process. Consult with mentor when in doubt. Adherence to defined processes. Adhere to organization’ s policies and business conduct.
10. Manage knowledge: Consume project related documents, share point, libraries and client universities
11. Issue Resolution:
• Identifies, analyses and solves the incidents/transactions.
• Perform root cause analysis to find corrective and preventive actions after every major incident and escalations. Work closely with team members to solve customer problems.
• Understand agent's problems and weaknesses and address
12. Release: Adhere to release management process
13. Team management:
• Set expectations; manage performance of team and individuals.
• Provide regular feedback.
• Coach team towards operational excellence.
• Recognize high performing talents in the team and reward them.
14. Mentoring:
• Guide new team members in understanding customer infrastructure and processes.
• Mentoring and providing guidance to the peers and junior associates.
• Assist new team members to understand the customer environment.
15. Management: Able to make decisions on any matters relating to improving revenue generation and customer satisfaction with regards to call handling and call center processes.
Skill Examples:
1. Customer Focus: Focus on providing a prompt and efficient service to customers; goes out of the way to ensure that individual customer needs are met.
2. Attention to detail to ensure metrics, quality and production output and reporting is accurate
3. Team Work: Respect others and work well within the team.
4. Communication: Speak clearly and write in a clear and concise manner. Uses appropriate style and language for communication (Data)
5. Communication: Speaks in an accent neutral manner or with the accent required for the process, with good vocabulary and grammar skills. Writes clearly (Voice)
6. Analysis and Decision Making: Makes judicious and fair decisions after examining all relevant information and making clear assumptions
7. Team Coaching and Leadership: Lead the team by example. Guide and support the team towards the achievement of goals.
8. Coaches and guides lead’s in managing outcomes and expectations well.
9. Manage and facilitate aspirations and skill development for team.
10. Proactive in avoiding or resolving conflicts.
11. Planning skills: Translate business objectives into functional activities. Set goals and processes and organize resources to ensure that the desired results are met.
12. Excellent communication and leadership skills.
13. Organizational and time management skills.
14. Assistant Manager - Operations, Training, Quality, MIS, Process Excellence
15. Leadership role with span of up to 60 FTEKnowledge Examples:
20. Familiar with Windows Operating Systems, MS Office
21. Excellent English comprehension – reading, writing and speaking
22. Domain knowledge based on process (healthcare, banking, investment, F&A, retail, customer support etc)
23. Expertise with process knowledge and guidelines
24. Expertise in work allocation and intake functions
25. Expertise in MS Excel
26. Expertise with quality control processes including pare to analysis and root cause analysis
27. Typing speed with 15WPM and 80% accuracy [Voice}
28. Typing speed with 30WPM and 95% accuracy [Data]
29. Experience level – 9 to 12 years