About this role
Role Overview
- Design and document comprehensive Desk Level Procedures (DLPs) across claims, benefits, enrollment, and configuration workflows
- Translate business processes and system functionality into clearly defined, step-by-step operational procedures for end users
- Develop DLPs that outline: Standard workflows Exception handling processes Step-by-step issue resolution procedures
- Ensure documentation is accurate, complete, and aligned with current Facets system behavior and business rules
- Partner with configuration teams to align DLPs with Facets system setup across membership, billing, claims, benefits, provider, and pricing modules
- Translate configuration logic into operational procedures for claims processing, adjustments, and issue resolution
- Support troubleshooting of claims and benefit-related issues tied to configuration gaps or system logic
- Validate that operational processes reflect accurate claims adjudication workflows and system dependencies
- Provide deep subject matter expertise in: Membership including premium billing Claims adjudication workflows Benefits configuration and plan design Provider payment and reimbursement processes
- Develop procedures that help teams: Investigate errors Identify configuration issues Execute corrections and reprocessing steps
- Ensure procedures support consistent, compliant claims and benefits operations
- Create DLPs that clearly outline: How to identify root causes of claims or configuration issues Step-by-step actions to resolve issues within Facets or downstream systems Escalation paths and cross-team dependencies
- Partner with operational and IT teams to analyze recurring issues and improve existing procedures
- Drive consistency in how teams diagnose and resolve claims, configuration, and workflow issues
- Collaborate with Claims, Enrollment, Provider Configuration, IT, and Operations teams to define and validate processes
- Translate complex technical and system concepts into clear, business-friendly documentation
- Support training initiatives by providing DLP documentation and operational guidance for end users
- Continuously evaluate and enhance DLPs to improve: Operational efficiency Accuracy and consistency Issue resolution timelines Standardized procedures across clients and environments to ensure repeatable, scalable delivery models
- Support system implementations, conversions, and operational transformations with DLP development
Requirements
- 5+ years of experience working within Healthcare Payer operations
- 5+ years of healthcare payer experience (Medicare and Medicaid)
- 5+ years of hands-on experience with Facets (TriZetto), particularly in: Premium billing Claims processing Benefits/Provider configuration Operational workflows
- Strong experience developing: Desk Level Procedures (DLPs) SOPs, workflows, or operational documentation
- Deep understanding of: Eligibility and premium billing Claims adjudication processes Benefits configuration and plan structures
- Proven ability to: Translate complex processes into clear, step-by-step instructions Troubleshoot and resolve system/process-related issues
- Experience working in a consulting or client-facing environment
Benefits
- medical, dental, and vision coverage to employees and dependents
- a 401(k) plan with a generous employer match
- an employee stock purchase plan
- a generous Paid Time Off policy
- paid parental leave and adoption assistance
- Our Wellness Program supports employee total well-being by providing free annual health screenings and coaching, bank at work, and on-site workshops, as well as ongoing programs recognizing major events in the lives of our employees throughout the year