Health Claims - Process & Quality Improvement

As a Quality and Process Manager in the Health Claims Operations team, your role is crucial in ensuring accurate, efficient, and compliant processing of claims while driving continuous improvement using Lean Six Sigma methodologies. Key Responsibilities: - Develop and implement quality control frameworks for health claims processing. - Monitor and audit claims to ensure accuracy, compliance, and timeliness. - Identify root causes of errors and lead corrective action plans. - Collaborate with training teams to address knowledge gaps and improve performance. - Apply Lean Six Sigma principles to identify and eliminate waste, reduce variation, and improve process efficiency. - Lead DMAIC projects to optimize claims workflows. - Conduct Value Stream Mapping and Failure Mode and Effects Analysis to assess process risks and opportunities. - Design and implement standardized operating procedures aligned with Six Sigma best practices. - Ensure adherence to regulatory requirements. - Maintain documentation for audits and regulatory inspections. - Monitor risk indicators and escalate potential issues proactively. - Work closely with claims processors, medical review teams, and customer service. - Liaise with external partners such as TPAs and hospitals. - Present performance metrics and improvement plans to senior leadership. Qualifications & Skills: - Bachelors degree in healthcare administration, Business, Engineering, or related field. - Lean Six Sigma Green Belt certification required; Black Belt preferred. - Additional certifications in quality management are a plus. - Strong knowledge of health claims lifecycle and adjudication processes. - Proficiency in Lean Six Sigma tools. - Advanced data analysis skills using Excel, Power BI, or statistical software. - Experience leading cross-functional process improvement projects. - Excellent communication, leadership, and stakeholder management skills. - Experience with digital claims platforms and automation tools preferred. - Familiarity with Indian health insurance regulations and global best practices. - Ability to thrive in a fast-paced, high-volume environment.,