About the role
Expertise in Claims Adjudication, Appeals Review, Contact Center preferred Responsibilities
- Manage the QE team (AMs and QCAs), covering certification, monitoring, feedback and productivity
- Drive governance through daily, weekly and monthly quality reporting, RCA and action plans, and client quality reviews
- Partner with Operations to improve accuracy, reduce errors and meet client SLAs and P4P metrics
- Support the transition by validating SOPs, building quality checkpoints and running UAT, dry runs and go-live readiness
- Lead process improvement and standardization projects using Lean Six Sigma tools
- Support internal and client audits, interactions and contribute to RFP/RFI responses when needed
- Mentor and develop team members
- 5–7 years of experience in Quality / Process Excellence, preferably in US Healthcare payer processes (claims, Medicare, appeals, prior auth or UM)
- Lean Six Sigma Green or Black Belt certification from a reputed organization
- Strong grasp of sampling, calibration, RCA and quality metrics
- Experience leading QE teams and working with Ops and client stakeholders
- Facets or similar claims platform exposure is an advantage
- Strong Excel, dashboard and reporting skills; Power BI is a plus
- Clear communication, comfortable presenting to leadership and clients
Primary skills (must-have)
- Quality Management / Quality Assurance
- US Healthcare – Payer
- Claims Adjudication
- Medicare / Medicare Advantage
- Lean Six Sigma (Green Belt / Black Belt)
- Root Cause Analysis (RCA)
- Audit Sampling and Calibration
- Process Improvement
- Team Management
- Stakeholder Management
Secondary skills (good to have)
- Facets
- Appeals and Grievances
- Prior Authorization / Utilization Management
- Transition Management
- SOP Development
- Power BI / Advanced Excel
- P4P / SLA Management
- Client Governance and Reporting