Job Description: Claims Business Consultant – Healthcare (Process Transformation & Automation)
Location: Remote / Hybrid
Experience: 5+ years
Industry: Healthcare | Payer & Provider Operations
Role Overview
We are looking for a Claims Business Consultant with deep expertise in healthcare claims operations and a strong track record in process transformation and automation advisory.
This role will partner with business and IT stakeholders to analyze, reimagine, and optimize claims processes, leveraging process intelligence, automation (RPA), and AI-led solutions. The consultant will play a critical role in bridging business needs with technology solutions, driving measurable improvements in efficiency, compliance, and cost.
Key Responsibilities
Business Consulting & Transformation Advisory
Act as a trusted advisor to healthcare operations leadership, guiding claims transformation initiatives
Assess current-state claims operations and define target operating models and transformation roadmaps
Identify opportunities to improve efficiency, cost, accuracy, and regulatory compliance
Support strategic initiatives across:
Claims adjudication
Denial management
Prior authorization
Revenue cycle optimization
Claims Process Analysis & Optimization
Analyze end-to-end claims lifecycle, including:
EDI 837/835 workflows
Eligibility verification
Claims submission and adjudication
Remittance and payment posting
Denials and appeals
Identify pain points, inefficiencies, and manual intervention areas
Drive root-cause analysis for denials, rework, and delays
Recommend process standardization and optimization strategies aligned to industry best practices
Process Intelligence & Insights
Leverage process and task mining insights (UiPath/Celonis or equivalent) to understand actual process execution
Translate data insights into business narratives and actionable recommendations
Define and track KPIs such as cycle time, accuracy, denial rate, and productivity
Enable stakeholders with data-driven decision-making frameworks and dashboards
Automation & Digital Enablement
Identify and shape automation opportunities (RPA, AI/ML) across claims workflows
Build business cases and ROI models for automation initiatives
Develop high-level solution concepts and process design inputs for RPA teams
Partner with architects and developers to ensure alignment between business objectives and technical solutions
Support automation lifecycle (discovery → design → UAT → hypercare) from a functional standpoint
Stakeholder Engagement & Change Management
Lead workshops and discussions with:
Claims operations teams
Billing and coding teams
Payer relations stakeholders
Present insights, recommendations, and transformation strategies to senior stakeholders
Drive alignment across business and IT teams
Support change adoption, communication, and process transition
Requirements
Requirements
Required Qualifications
5+ years of experience in healthcare claims operations, business consulting, or process transformation
Strong expertise in end-to-end claims lifecycle (EDI 837/835, prior auth, adjudication, denials, appeals)
Experience working with claims platforms such as:
Epic (Resolute HB/PB), Facets, TriZetto, Availity, Change Healthcare
Hands-on exposure to:
Process mining / task mining tools (UiPath, Celonis, etc.)
Automation platforms (UiPath preferred)
Strong capabilities in:
Business analysis and consulting
Process re-engineering
ROI and business case development
Good understanding of:
HIPAA compliance and healthcare regulatory requirements
Excellent stakeholder management and communication skills
Benefits
Benefits
Preferred Qualifications
Experience in digital transformation or consulting engagements (healthcare domain)
Certification in:
UiPath Process Mining / RPA
Lean / Six Sigma
Working knowledge of:
SQL / data analysis
HL7, FHIR, interoperability standards
Exposure to AI-led transformation use cases in healthcare operations
PMP / Agile certification
What Success Looks Like
Defined and executed claims transformation roadmap with measurable business outcomes
Delivery of high-impact automation use cases with validated ROI
Reduction in:
Claims processing time
Denial rates
Manual effort and rework
Improved process visibility and governance through dashboards and KPIs
Strong business adoption and sustained improvements across claims operations
Key Competencies
Business consulting and stakeholder advisory
Deep claims domain expertise
Analytical thinking and structured problem-solving
Strong communication and executive presentation skills
Ability to translate business challenges into technology-enabled solutions