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Overview
This role leads operations strategy and service design for Core Administration Business Process as a Service (BPaaS) programs. You will work closely with health plan executives, operations leaders, and transformation teams to shape future-state operating models, guide modernization strategy, and support sales pursuits.
You Are: A senior health plan operations strategist with deep experience across Core Administration domains. You understand payer operations end-to-end and can translate complex operational challenges into measurable, scalable BPaaS solutions. You excel in designing service models, developing modernization roadmaps, and guiding clients through operational transformation. You are comfortable leading executive workshops, shaping BPaaS value propositions, and bridging the gap between operational realities and modern platform capabilities.
The Opportunity
BPaaS Solution Design & Core Admin Modernization
- Lead service model design and solution blueprinting for health plan Core Administration transformation initiatives.
- Assess current-state operations on legacy platforms (e.g., Facets, QNXT, Javelina, QicLink, homegrown) and define transition pathways to BPaaS delivery models on the HealthEdge ecosystem, including HealthRules Payer (HRP).
- Design future-state operating models spanning claims, enrollment, billing, provider relations, UM, A&G, benefits administration, and member operations—with a focus on service delivery efficiency, scalability, and outcomes.
Operational Ecosystem & Service Integration Strategy
- Define how BPaaS service layers connect across the health plan ecosystem—including care management, provider data management, payment integrity, member engagement, and analytics.
- Identify opportunities to embed automation, AI-enabled workflows, and intelligent process orchestration into operational service models.
- Recommend operating model patterns that reduce administrative burden, improve turnaround times, and drive measurable cost and quality outcomes.
Sales & Pursuit Leadership
- Support Advisory and Sales teams on strategic BPaaS pursuits, proposals, and RFP responses.
- Lead operational discussions with COOs, VP Operations, and business transformation leaders—translating BPaaS capabilities into health plan business outcomes.
- Develop business cases demonstrating cost reduction, operational efficiency, scalability, and compliance improvements.
Transformation Advisory
- Conduct current-state assessments of Core Admin operations, staffing models, and process maturity.
- Create modernization roadmaps and platform transition strategies grounded in operational realities and health plan business priorities.
- Ensure proposed BPaaS solutions align with regulatory requirements, accreditation standards, and long-term operational scalability.
Collaboration & Leadership
- Mentor team members on Core Admin operational domains, BPaaS service design principles, and health plan business context.
- Partner with technology and delivery teams to ensure operational feasibility and alignment with service model commitments.
- Represent Advisory in client workshops, executive sessions, and strategic planning forums.
Qualifications
Required
- 5+ years in health plan operations, Core Administration, or healthcare BPaaS strategy.
- Deep operational expertise across one or more Core Admin domains: claims, enrollment, billing, benefits administration, UM, A&G, provider, and member services.
- Prior consulting, managed services, or advisory experience with a health plan, SI, or BPaaS vendor.
- Proven ability to assess operational models and design future-state BPaaS service blueprints.
- Strong familiarity with Core Admin platforms (HealthRules Payer, Facets, QNXT, QicLink, Javelina, or equivalent).
- Strong sales-facing skills: whiteboarding, pursuit support, and executive communication with health plan leadership.
- Exceptional analytical, communication, and client-facing presence.
Preferred
- Experience leading or advising on migrations from legacy platforms to modern SaaS or BPaaS delivery models.
- Familiarity with AI/ML, intelligent automation, and digital operations transformation within health plan settings.
Location: Remote – US Travel required for client sessions, workshops, and internal collaboration.
HealthEdge commits to building an environment and culture that supports the diverse representation of our teams. We aspire to have an inclusive workplace. We aspire to be a place where all employees have the opportunity to belong, make an impact and deliver excellent software and services to our customers.
Geographic Responsibility: While HealthEdge is located in Boston, MA you may live anywhere in the US Type of Employment: Full-time, permanent FLSA Classification (USA Only): Exempt
Work Environment: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job:
- The employee is occasionally required to move around the office. Specific vision abilities required by this job include close vision, color vision, peripheral vision, depth perception, and ability to adjust focus.
- Work across multiple time zones in a hybrid or remote work environment.
- Long periods of time sitting and/or standing in front of a computer using video technology.
- May require travel dependent on company needs.
The above statements are intended to describe the general nature and level of the job being performed by the individual(s) assigned to this position. They are not intended to be an exhaustive list of all duties, responsibilities, and skills required. HealthEdge reserves the right to modify, add, or remove duties and to assign other duties as necessary. In addition, reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of this position in compliance with the Americans with Disabilities Act of 1990. Candidates may be required to go through a pre-employment criminal background check.
HealthEdge is an equal opportunity employer. We are committed to workforce diversity and actively encourage all qualified persons to seek employment with us, including, but not limited to, racial and ethnic minorities, women, veterans and persons with disabilities.
**The annual US base salary range for this position is $135,000 to $155,000. This salary range may cover multiple career levels at HealthEdge. Final compensation will be determined during the interview process and is based on a combination of factors including, but not limited to, your skills, experience, qualifications and education.
