Health Payer Operations Manager (Claims Operations)

Accenture•Chicago, IL

11d

About The Position

Accenture is a leading global professional services company that helps the world’s leading businesses, governments and other organizations build their digital core, optimize their operations, accelerate revenue growth and enhance citizen services—creating tangible value at speed and scale. We are a talent- and innovation-led company with approximately 750,000 people serving clients in more than 120 countries. Technology is at the core of change today, and we are one of the world’s leaders in helping drive that change, with strong ecosystem relationships. We combine our strength in technology and leadership in cloud, data and AI with unmatched industry experience, functional expertise and global delivery capability. We are uniquely able to deliver tangible outcomes because of our broad range of services, solutions and assets across Strategy & Consulting, Technology, Operations, Industry X and Song. These capabilities, together with our culture of shared success and commitment to creating 360° value, enable us to help our clients reinvent and build trusted, lasting relationships. We measure our success by the 360° value we create for our clients, each other, our shareholders, partners and communities. Visit us at www.accenture.com. Strategy & Consulting: We work with C-suite executives, leaders and boards of the world’s leading organizations, helping them reinvent every part of their enterprise to drive greater growth, enhance competitiveness, implement operational improvements, reduce cost, deliver sustainable 360° stakeholder value, and set a new performance frontier for themselves and the industry in which they operate. Our deep industry and functional expertise is supported by proprietary assets and solutions that help organizations transform faster and become more resilient. Underpinned by technology, data, analytics, AI, change management, talent and sustainability capabilities, our Strategy & Consulting services help architect and accelerate all aspects of an organization’s total enterprise reinvention. As a Health Payer Operations Manager/Consultant, your primary responsibilities may include: Claims Operations Lead initiatives to improve claims processing efficiency and accuracy, reducing operational costs and improving member satisfaction. Analyze claims workflows and identify bottlenecks or opportunities for automation to streamline processes. Transform traditional operating models and process to incorporate innovative designs with advanced technologies Ensure compliance with all regulatory requirements and payer policies across claims operations. Partner with Technology teams to shape claims platform configuration and optimization Strategic Operations & Improvement Initiatives Develop, implement, and monitor process improvement initiatives across claims and provider operations. Utilize data analytics and operational metrics to identify trends, monitor performance, and recommend adjustments as needed. Lead training and support change management efforts for new initiatives to ensure smooth transitions and process adoption. Design and operationalize KPI and performance management frameworks to monitor claims health and support executive decision-making. Stakeholder Management & Collaboration Partner with internal teams (e.g., IT, compliance, customer service) to ensure project goals align with organizational priorities. Communicate effectively with senior leadership, providing regular updates and progress reports. Serve as a subject matter expert and provide guidance to junior consultants or team members. Contribute to Health Administration consulting practice by mentoring junior team members, maintain currency on industry events and trends as well as develop thought leadership to advance industry perspectives on emerging trends. Compliance & Risk Management Maintain current knowledge of state and federal health payer regulations and ensure compliance across all operational activities. Identify and mitigate operational risks within claims and network operations. Proactively identify risk as part of consulting engagements and frame mitigation strategies in partnership with project leadership. Leading Transformational Change Lead large-scale transformation initiatives in health payer operations, focusing on streamlining processes, enhancing service delivery, and achieving operational excellence. Drive transformational change and lead change initiatives that require a deep understanding of functional processes, combined with the ability to navigate across business domains and align with emerging technologies.

Requirements

Bachelor’s degree in Healthcare Administration, Business, or related field.
Minimum of 3 years of experience in healthcare consulting or enterprise operations improvement, with a focus with payer and/or provider clients.
Minimum of 3 years of experience in health payer operations, particularly in claims and/or provider network operations.

Nice To Haves

Master's degree preferred.
Experience working with or leading global teams.
Thrive in a diverse, fast paced environment.
An advanced degree in the area of specialization.
Exceptional problem-solving and analytical skills.
Excellent communication and presentation abilities.
Leadership experience, including team management and project oversight.
Experience in creating and delivering agentic AI solutions for Claims or other Operations functions
Experience with industry leading claim adjudication platforms and related technology, and payment integrity vendors.
Strong knowledge of health insurance regulatory requirements, payer policies, and claims adjudication.
Proven experience leading and executing process improvement projects in a healthcare setting.
Proficiency in data analysis and operational metrics; experience with relevant software/tools (e.g., claims management systems, data visualization platforms).
Ability to work independently and collaboratively in a fast-paced, client-focused environment.

Responsibilities

Claims Operations Lead initiatives to improve claims processing efficiency and accuracy, reducing operational costs and improving member satisfaction.
Analyze claims workflows and identify bottlenecks or opportunities for automation to streamline processes.
Transform traditional operating models and process to incorporate innovative designs with advanced technologies
Ensure compliance with all regulatory requirements and payer policies across claims operations.
Partner with Technology teams to shape claims platform configuration and optimization
Develop, implement, and monitor process improvement initiatives across claims and provider operations.
Utilize data analytics and operational metrics to identify trends, monitor performance, and recommend adjustments as needed.
Lead training and support change management efforts for new initiatives to ensure smooth transitions and process adoption.
Design and operationalize KPI and performance management frameworks to monitor claims health and support executive decision-making.
Partner with internal teams (e.g., IT, compliance, customer service) to ensure project goals align with organizational priorities.
Communicate effectively with senior leadership, providing regular updates and progress reports.
Serve as a subject matter expert and provide guidance to junior consultants or team members.
Contribute to Health Administration consulting practice by mentoring junior team members, maintain currency on industry events and trends as well as develop thought leadership to advance industry perspectives on emerging trends.
Maintain current knowledge of state and federal health payer regulations and ensure compliance across all operational activities.
Identify and mitigate operational risks within claims and network operations.
Proactively identify risk as part of consulting engagements and frame mitigation strategies in partnership with project leadership.
Lead large-scale transformation initiatives in health payer operations, focusing on streamlining processes, enhancing service delivery, and achieving operational excellence.
Drive transformational change and lead change initiatives that require a deep understanding of functional processes, combined with the ability to navigate across business domains and align with emerging technologies.