Company Statement
EmblemHealth is one of the nation’s largest not for profit health insurers, serving members across New York’s diverse communities with a full range of commercial and government-sponsored health plans for employers, individuals, and families. With a commitment to value-based care, EmblemHealth partners with top hospitals and doctors, including its own AdvantageCare Physicians, to deliver quality, affordable, convenient care. At over a dozen EmblemHealth Neighborhood Care locations, members and non-members alike have access to community-based health and wellness guidance and resources. For more information, visit emblemhealth.com.
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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.
Qualifications
Education, Training, Licenses, Certifications
- Bachelor’s Degree required
Relevant Work Experience, Knowledge, Skills, and Abilities
- 4–6+ years of relevant experience in healthcare payer operations (Claims strongly preferred) or management consulting with a focus on operational performance improvement required
- Experience leading or independently executing process improvement initiatives, operational optimization efforts, or system implementations required
- Experience working across cross-functional teams, including Operations and Technology partners required
- Demonstrated ability to operate independently, manage multiple work efforts, and drive initiatives to completion with minimal oversight required
- Strong understanding of end-to-end healthcare operations workflows, including upstream & downstream dependencies required
- Experience working with vendors and/or offshore teams in an operational or project capacity required
- Strong analytical and problem-solving skills, including root cause analysis and data interpretation required
- Proficiency with MS Office (Excel, PowerPoint, MS Project, Teams, Outlook) and process mapping tools (e.g., Visio) required
- Experience with Agile tools such as Jira or Azure DevOps required
- Strong written and verbal communication skills, including development of structured presentations and materials for leadership audiences required
- Experience with automation, AI-enabled solutions, or workflow optimization tools preferred
Security Disclosure
If you receive a job offer from EmblemHealth, the email will be from “HRTalentAcquisition” with the subject: “Offer of Employment for (job title) – Please respond online.” We will never ask you to join a Google Hangout, buy your own equipment, or pay to apply. We also do not use third-party email services like Yahoo or Gmail.
Pay Disclosure
At EmblemHealth, we prioritize transparency in our compensation practices. We provide a good faith estimate of the salary range for potential hires, which is based on key factors such as role responsibilities, candidate experience, education and training, internal equity, and market conditions. Please be aware that this estimate doesn’t account for geographic differences related to your work location. Typically, new hires may not start at the top of this range, as compensation is tailored to each individual's circumstances. For union positions, salaries will be determined according to the collective bargaining agreement. Join us at EmblemHealth, where your contributions are valued and supported by fair compensation.
EEOC Statement
We value the diverse backgrounds, perspectives, and experiences of our workforce. As an equal opportunity employer, we consider all qualified applicants for employment regardless of race, color, religion, sex, sexual orientation, age, creed, citizenship status, gender identity, pregnancy, marital status, national origin, disability, veteran status, or any other protected characteristic protected by law.
Sponsorship Statement
At EmblemHealth, we are committed to building a diverse and talented workforce. However, we are unable to consider applicants who require, or are likely to require, either before or after hire, visa sponsorship for work authorization in the United States, including but not limited to H-1B, F-1 (STEM OPT), TN, or any other non-immigrant status. Some extremely rare exceptions may apply based on critical business needs.