Job Description:
• Lead service model design and solution blueprinting for health plan Core Administration transformation initiatives.
• Assess current-state operations on legacy platforms and define transition pathways to BPaaS delivery models on the HealthEdge ecosystem.
• Design future-state operating models spanning claims, enrollment, billing, provider relations, UM, A&G, benefits administration, and member operations.
• Define how BPaaS service layers connect across the health plan ecosystem.
• Identify opportunities to embed automation, AI-enabled workflows, and intelligent process orchestration into operational service models.
• Develop business cases demonstrating cost reduction, operational efficiency, scalability, and compliance improvements.
• Conduct current-state assessments of Core Admin operations, staffing models, and process maturity.
• Create modernization roadmaps and platform transition strategies grounded in operational realities and health plan business priorities.
Requirements:
• 5+ years in health plan operations, Core Administration, or healthcare BPaaS strategy.
• Deep operational expertise across one or more Core Admin domains: claims, enrollment, billing, benefits administration, UM, A&G, provider, and member services.
• Prior consulting, managed services, or advisory experience with a health plan, SI, or BPaaS vendor.
• Proven ability to assess operational models and design future-state BPaaS service blueprints.
• Strong familiarity with Core Admin platforms (HealthRules Payer, Facets, QNXT, QicLink, Javelina, or equivalent).
Benefits:
• Health insurance
• 401(k) matching
• Paid time off
• Remote work options
• Professional development