Senior Payment Integrity Program Consultant, Claims Recovery

Position Purpose: The Senior Business Process Consultant leads business case development for proposed initiatives, supports the strategic planning process, and leads larger scale, cross-functional initiatives.

Key Details: Must be authorized to work in the U.S. without the need for employment-based visa sponsorship now or in the future. Sponsorship and future sponsorship are not available for this opportunity, including employment-based visa types H-1B, L-1, O-1, H-1B1, F-1, J-1, OPT, or CPT.

Healthcare claims or Payment Integrity experience, with knowledge of recovery, COB/TPL, subrogation, or related claims operation highly preferred.

Strong cross-functional program and process leadership skills, with experience partnering across business, technology, operations, and external vendors highly preferred.

Strong data analysis and performance monitoring skills, with the ability to evaluate operational and financial metrics and support reporting, audit, and compliance needs preferred.

Experience translating business needs into process or technology requirements and identifying opportunities for process improvement, automation, governance, and stronger operational controls a plus.

Lead cross-functional initiatives across Payment Integrity, Claims, technology teams, and external vendors, coordinating priorities, dependencies, risks, and deliverables.

Drive implementation and ongoing optimization of CRP-to-Claims processes, ensuring recovery activity is accurately integrated into claims operations.

Manage complex exceptions, reconciliations, defects, and escalations, partnering with business and technology stakeholders to identify root causes and drive issues through resolution.

Leads business case development for proposed initiatives to ensure adequate assessment of opportunities, risks and return on investment.

Provides input and supports planning and prioritization of initiatives as part of the strategic and business planning process.

Ensures that initiatives support the strategic business plan, meet key business objectives and are executed well tactically.

Ensures that all approved business cases are transitioned to initiatives (both documentation and clear responsibilities for each initiative).

Leads larger scale, cross-functional initiatives that are intended to drive performance improvement, financial gains, customer satisfaction and improved compliance.

Provides strategic and policy guidance on assigned initiatives so that all processes are considered for maximizing effective implementation and results.

Organizes work teams, drives consensus and ensures end to end policy/process integrity to accomplish project work: including identification and confirmation of participants, establishment of a project plan, consistent work team engagement and productivity, meeting facilitation, consensus building, recommendation documentation and implementation oversight.

Performs detailed analysis of data, workflows, policies, procedures, organization of staff, and skills in order to execute initiatives.

Supports the project work by utilizing project management software such as, but not limited to, Excel, PowerPoint, Visio, and Microsoft Project.

Leads all levels of staff who are responsible for initiatives included in the companies operating plan in order to support their success, development and effective completion and communication of their initiative.

Assists other project leaders in specific areas as needed such as facilitation, analysis, process mapping, brain-storming, project management issues, etc.