Senior Process & Performance Optimization Specialist

Summary of Position

• Responsible for executing and driving initiatives and ongoing optimization efforts that improve performance across end-to-end Operations, including Claims, Provider Operations, Compliance, Grievance & Appeals, Enrollment & Billing, and Call Center functions with minimal oversight.
  
• Acts as a cross-functional execution lead who identifies operational challenges and improvement opportunities through data analysis and stakeholder engagement, translates business needs into structured work efforts, and drives initiatives through completion.
  
• Partners with Operations, IT, vendors, offshore teams, and upstream/downstream stakeholders to ensure that process improvements, system enhancements, and workflow changes are effectively implemented, adopted, and deliver measurable operational outcomes.
  
• Operates with a high degree of autonomy, managing work efforts from intake through execution while ensuring alignment with business priorities.

Principal Accountabilities

• Independently drive execution of initiatives and work efforts from intake through completion across Operations
  
• Define and structure assigned work efforts, including scope, objectives, milestones, deliverables, risks, and dependencies
  
• Develop and maintain detailed execution plans using tools such as Excel, MS Project, Smartsheet, or Agile platforms (Jira/Azure DevOps)
  
• Identify and engage appropriate stakeholders across Operations, IT, vendors, offshore teams, and upstream/downstream partners
  
• Lead working sessions to align objectives, progress, and issue resolution
  
• Proactively identify execution risks, blockers, and gaps; drive resolution through direct engagement and follow-up
  
• Ensure clear ownership and accountability for action items and deliverables across stakeholders.
  
• Escalate issues with context, data, and recommended solutions to leadership when needed
  
• Validate that initiatives are completed with measurable operational impact and aligned to defined success criteria
  
• Identify and drive improvements across end-to-end operational workflows spanning multiple business areas.
  
• Conduct current-state assessments through stakeholder interviews, workflow walkthroughs, and job shadowing
  
• Analyze processes across functional boundaries (e.g., Enrollment Claims Appeals Call Center)
  
• Develop detailed process maps including decision points, handoffs, rework loops, and system interactions
  
• Quantify inefficiencies using data such as cycle time, backlog, error/rework rates, and productivity metrics
  
• Perform root cause analysis across people, process, and technology dimensions.
  
• Identify and define improvement opportunities that are practical, scalable, and aligned to business constraints.
  
• Evaluate upstream and downstream impacts of proposed changes
  
• Drive implementation of process improvements, including stakeholder alignment and operational readiness.
  
• Validate effectiveness of changes post-implementation and adjust as needed.
  
• Translate operational needs into clearly defined requirements and support successful delivery of system and workflow changes.
  
• Gather and synthesize business requirements through structured stakeholder engagement
  
• Translate needs into user stories, business requirements, acceptance criteria, and process workflows, ensuring requirements reflect operational realities, dependencies, and success measures.
  
• Partner with IT and product teams to refine backlog items and clarify priorities.
  
• Develop test scenarios and lead coordination of User Acceptance Testing (UAT)
  
• Track defects, ensure resolution, and validate system functionality.
  
• Confirm alignment between delivered solutions and intended operational outcomes.
  
• Partner with stakeholders to ensure readiness for implementation.
  
• Support data-driven decision-making and monitor operational performance and initiative outcomes.
  
• Extract, compile, and analyze data across multiple operational areas (Claims, Call Center, Enrollment, etc.).
  
• Track key performance indicators, including but not limited to: Inventory and backlog levels, Turnaround times, First-pass yield / accuracy rates, Productivity and utilization metrics.
  
• Develop working dashboards, scorecards, and tracking tools using Excel or Power BI.
  
• Identify trends, performance gaps, and emerging risks.
  
• Provide actionable, data-driven insights and recommendations to stakeholders and leadership.
  
• Identify and support implementation of automation and efficiency opportunities across Operations.
  
• Identify repetitive, manual, or high-volume processes suitable for automation (RPA, AI-enabled solutions, workflow tools).
  
• Document use cases, including current-state effort, expected benefits, and operational impact.
  
• Evaluate feasibility and prioritize opportunities based on value and complexity.
  
• Participate in testing, validation, and rollout of automated solutions.
  
• Monitor early performance and track realization of expected benefits.
  
• Identify and address issues impacting performance or adoption.
  
• Ensure effective rollout, adoption, and sustainability of process and system changes by developing and executing practical rollout plans aligned with operational workflows and constraints.
  
• Create clear and usable documentation, including job aids, process guides, and training materials.
  
• Support training sessions, stakeholder walkthroughs, and working sessions.
  
• Engage operations teams, vendors, and offshore partners to ensure understanding and readiness.
  
• Gather feedback from end users and identify adoption challenges.
  
• Identify risks related to change adoption (e.g., workarounds, resistance, knowledge gaps).
  
• Drive or recommend corrective actions to ensure sustained adoption and performance.
  
• Drive alignment and communication across stakeholders and provide visibility to leadership.
  
• Identify and engage relevant stakeholders across Operations, IT, vendors, and partner teams.
  
• Facilitate working sessions, discussions, and problem-solving forums.
  
• Develop structured materials and presentations for leadership updates.
  
• Communicate initiative progress, risks, issues, and outcomes clearly and concisely.
  
• Present findings, insights, and recommendations to Director- and SVP-level stakeholders as needed.
  

• Ensure alignment across stakeholders on priorities, expectations, and outcomes.