Business Process Reengineering (BPR) Consultant Healthcare Payer

Job Title: Business Process Reengineering (BPR) Consultant Healthcare Payer

Location: NYC- Work from office at least 3 days from office

Experience

6 12+ years (Healthcare Payer domain with Business Process Transformation experience)

Job Summary

We are seeking an experienced Business Process Reengineering (BPR) Consultant with strong expertise in the healthcare payer industry to analyze, redesign, and optimize business processes across payer operations. The ideal candidate will possess deep knowledge of healthcare payer functions, process improvement methodologies, digital transformation, and stakeholder management. This role involves collaborating with business and technology teams to improve operational efficiency, enhance member and provider experience, reduce costs, and support strategic transformation initiatives.

Healthcare Payer Domain Expertise

Lead or support transformation initiatives across functions such as:

• Member enrollment and eligibility
• Claims intake, adjudication, and payment
• Provider contracting and credentialing
• Provider network management
• Utilization Management (UM)
• Care Management (CM)
• Case Management
• Prior Authorization
• Appeals and Grievances
• Customer Service / Contact Center
• Payment Integrity
• Coordination of Benefits
• Risk Adjustment
• Quality programs (HEDIS, STAR Ratings)
• Value-Based Care operations

Required Qualifications

• Bachelor's degree in Business, Engineering, Healthcare Administration, Information Systems, or a related field.
• 6 12+ years of experience in Business Process Reengineering, Process Excellence, Consulting, or Business Transformation.
• At least 4 6 years of experience in the healthcare payer industry.
• Strong understanding of commercial, Medicare, and/or Medicaid payer operations.
• Experience documenting As-Is and To-Be processes.
• Strong analytical and problem-solving skills.
• Excellent communication, facilitation, and stakeholder management abilities.

Preferred Qualifications

• Master's degree (MBA, MHA, or related discipline).
• Lean Six Sigma Green Belt or Black Belt certification.
• BPM certification (CBPP or equivalent).
• Experience with Agile methodologies.
• Knowledge of healthcare interoperability standards (HL7, FHIR, X12) is an advantage.

Required Skills

Business Process

• Business Process Reengineering (BPR)
• Business Process Management (BPM)
• Process Mapping
• Process Mining
• Value Stream Mapping
• Operating Model Design
• SOP Development
• Continuous Improvement
• Root Cause Analysis

Healthcare Payer

• Claims Operations
• Enrollment & Eligibility
• Provider Operations
• Medical Management
• Prior Authorization
• Appeals & Grievances
• Payment Integrity
• Risk Adjustment
• Medicare & Medicaid
• Commercial Health Insurance

Technology

• BPM platforms (e.g., Pega, Appian, IBM BPM, Camunda)
• Process modeling tools (Visio, Lucidchart, Signavio, ARIS)
• Microsoft Power Platform
• RPA (UiPath, Automation Anywhere, Blue Prism)
• Data visualization tools (Power BI, Tableau)
• SQL (preferred)

Methodologies

• Lean
• Six Sigma
• Design Thinking
• Agile
• Change Management
• Project Management

Key Competencies

• Strategic thinking
• Process optimization
• Business analysis
• Consulting and facilitation
• Executive communication
• Cross-functional collaboration
• Data-driven decision-making
• Customer-centric mindset
• Leadership and influence

Success Metrics

• Reduction in process cycle time
• Improvement in claims accuracy and first-pass adjudication
• Increased automation and straight-through processing
• Cost savings through process optimization
• Improved provider and member satisfaction
• Compliance with regulatory requirements
• Achievement of operational KPI targets

Preferred Industry Experience

• Commercial Health Insurance
• Medicare Advantage
• Medicaid Managed Care
• Third-Party Administrators (TPAs)
• Healthcare BPO/KPO
• Healthcare Consulting
• Managed Care Organizations (MCOs)

Nice-to-Have Experience

• Digital transformation programs
• AI-enabled process optimization
• Process mining tools (Celonis, SAP Signavio Process Intelligence)
• Cloud-based healthcare platforms
• Enterprise transformation initiatives
• Vendor and outsourcing management