Health Payer Operations Consultant/Manager

Health Consulting | Payer Operations Consultant/Manager
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 Consultant/Manager, 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.

• Ensure compliance with all regulatory requirements and payer policies across claims operations.

• Manage projects aimed at optimizing provider network operations, including provider onboarding, credentialing, contracting, and directory accuracy.

• Collaborate with network teams to improve provider experience and ensure network adequacy and accessibility standards are met.

• Evaluate provider relations and contracting processes to support payer-provider alignment and value-based care 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.

• 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.

• 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.

• 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.

• Travel - as needed, up to 80%

• Innovate every day. Be at the forefront of designing health technology solutions that push boundaries and create new opportunities for our clients.

• Lead with the industry's best. Join an industry-recognized healthcare leader with more than 20,000 global healthcare professionals collaborating to drive enterprise-wide transformational projects on a global scale. Accenture has worked with more than 200 clients to deliver healthcare transformation to meet the diverse needs of patients and members.

• Learn and grow continuously. Harness unmatched training and professional development to help you build and advance your health, consultative and delivery skills. With learning resources, interactive classroom courses, real-life client simulations and ongoing mentoring available when you need it, you'll expand your thinking beyond the core Workday implementation.

• 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.

• Master's degree preferred.
• 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.

• 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.

• Familiarity with reimbursement innovation, value-based care models and payer-provider alignment strategies.