Senior Payer Process Assessment & BPM Lead

CGI•Canton, MA

12h•Onsite

About The Position

We are seeking a Healthcare Subject Matter Expert (SME) – Payer who brings deep expertise in payer-domain operations and processes. This individual will play a critical role in evaluating and analyzing current-state workflows across key functions such as claims, provider operations, member services, utilization management, care management, and finance. The SME will collaborate closely with the Business Process Center of Excellence (BPCoE), process owners, analysts, and change managers to identify process gaps, improvement opportunities, compliance requirements, risks, and operational inefficiencies. By ensuring that all process assessments are accurate, industry-aligned, and reflective of real operational needs, the SME will help drive transformation initiatives that enhance efficiency and compliance within payer environments. Ideal candidates will possess deep healthcare payer knowledge, including a thorough understanding of regulatory requirements, operational workflows, and industry best practices. They will have a proven track record of conducting comprehensive process assessments, validating accuracy and completeness, and delivering actionable insights that support strategic decision-making. This is an opportunity to leverage your domain expertise to influence enterprise-level improvements and shape the future of healthcare operations. This position is located in our client office in Canton, MA.

Requirements

Deep, practical experience in payer operations such as: o Claims processing o Provider data management o Auth/UM/CM workflows o Appeals & grievances o Enrollment & billing o Member services o Network operations
Understanding of payer regulatory landscape (CMS, state regulations, NCQA, URAC).
Serve as a domain advisor during stakeholder engagement sessions.
Familiarity with emerging payer trends, interoperability standards, and digital health initiatives.
Ability to interpret and apply compliance requirements to operational processes.
Process Assessment Skills
Strong process discovery and mapping capability.
Ability to quickly identify gaps, inefficiencies, compliance risks.
Familiarity with Lean, Six Sigma, or BPC concepts is a plus.
Experience conducting end-to-end process assessments and gap analyses.
Ability to translate findings into actionable recommendations for process improvement.
Communication & Collaboration
Ability to work with Process Owners, SMEs, Analysts, governance teams.
Strong verbal and written communication skills.
Ability to explain complex operations in simple terms.
Skilled in facilitating workshops and stakeholder sessions to drive consensus.
Ability to present findings and recommendations to senior leadership effectively.
Tools & Documentation
Comfortable working with process maps, SIPOCs, workflows.
Familiarity with SharePoint or similar repositories.
Ability to review, annotate, and validate detailed documentation.
Proficiency in BPM tools (e.g., Visio, Signavio, ARIS, or similar).
Understanding of documentation standards and metadata requirements for enterprise process repositories.
Process Skills
Strong expertise in BPMN modeling.
Ability to analyze and assess complex workflows.
Understanding of Lean or Six Sigma (preferred).
Ability to create Level 1–5 process maps aligned with organizational standards.
Problem Solving & Analysis
Identifying gaps, risks, root causes, inefficiencies.
Developing practical recommendations.
Ability to prioritize recommendations based on impact, feasibility, and compliance needs.
Strong analytical mindset with attention to detail and operational accuracy.

Responsibilities

Process Discovery & Assessment
Conduct current-state process assessments across payer operations.
Facilitate process discovery sessions with business teams, process owners, and SMEs.
Document workflows, handoffs, pain points, variations, and system dependencies.
Identify inefficiencies, risks, compliance issues, and operational gaps.
Assess alignment with payer regulations (CMS, NCQA, URAC, HIPAA, state-level mandates).
Validate process inventory accuracy for payer-specific functions.
Collaborate with cross-functional teams to ensure operational realities are captured accurately.
Provide domain-driven insights to support transformation initiatives and compliance audits.
Process Documentation Support
Provide detailed domain knowledge to enrich process maps, SIPOCs, workflow steps, and process metadata.
Validate draft process documentation created by Analysts or Process Owners.
Ensure payer-specific terminology, coding, clinical requirements, and compliance factors are captured accurately.
Use templates, standards, and documentation requirements defined by the BPCoE.
Act as a quality gatekeeper for documentation accuracy and completeness before sign-off.
Process Maturity & Quality Evaluation
Evaluate processes against payer best practices and industry benchmarks.
Identify maturity gaps (e.g., manual vs. automated steps, fragmented workflows, non-compliant areas).
Provide input to AI Engineer and Reporting Analyst to refine quality scoring criteria.
Recommend payer-specific quality metrics to assess process performance.
Support development of process improvement roadmaps based on maturity assessments.
Process Assessments (Core Responsibility)
Conduct end-to-end process assessments for payer operations.
Lead or support process discovery sessions with POs/SMEs/Analysts.
Document operational pain points, handoff issues, inefficiencies, and compliance risks.
Identify automation potential, workflow redundancies, rework points, and failure modes.
Ensure assessments align with strategic objectives and regulatory compliance standards.
Develop BPMN Process Flows (New addition per your request)
Create detailed BPMN process maps for current-state and future-state processes.
Ensure models reflect correct:
roles/swimlanes
decision points
system interactions
compliance checkpoints
variations/exception flows
Validate BPMN diagrams created by Analysts and update them based on SME knowledge.
Prepare BPMN flows that align with BPCoE mapping standards (Level 1–5 as required).
Provide guidance on BPMN best practices and ensure consistency across enterprise documentation.
Identify Gaps & Create Recommendations (Expanded per request)
Conduct detailed gap analyses comparing current-state vs:
payer industry best practices
regulatory requirements
operational performance expectations
future-state BPCoE standards
Provide actionable, prioritized recommendations for:
process redesign
efficiency gains
compliance improvements
automation/RPA opportunities
documentation enhancements
Produce gap/recommendation reports for pilot and enterprise documentation.
Present findings and recommendations to leadership and stakeholders for decision-making.
Documentation Validation & Quality Assurance
Review process documentation for accuracy, completeness, compliance alignment, and payer-specific accuracy.
Validate that all required metadata, roles, and steps are reflected correctly.
Partner with the AI Engineer to refine AI scoring rules based on real payer nuances.
Ensure all BPMN and documentation follows BPCoE standards and templates.
Maintain version control and audit readiness for all process documentation.