Position Details: Solution Architect in Healthcare-Healthcare_CMS Grievances, Frau

The Solution Architect is responsible for leading large-scale U.S. healthcare payer contact center operations across Member Services, Provider Services, Claims, Enrollment, and Eligibility. This role owns end-to-end delivery excellence including SLAs, regulatory compliance, financial performance, workforce productivity, and transformation initiatives across Commercial, Medicare, and Medicaid lines of business. The role serves as a senior client-facing leader managing complex multi-LOB healthcare operations while driving cost optimization, quality, and AI-led transformation.

Responsibilities and Duties: 

• Provide hands on leadership for 200 - 400+ FTE U.S. healthcare contact center operations across Member Services, Provider Services, Claims, Enrollment, and Eligibility

• Act as a U.S. payer domain SME with deep understanding of member and provider journeys

• Own end to end KPIs and SLAs including AHT, ASA, FCR, quality, accuracy, grievance TAT, and appeals resolution

• Ensure compliance with U.S. healthcare regulations including HIPAA, CMS, Medicare, Medicaid, ACA, and state mandates

• Lead governance with U.S. payer leadership across Operations, CX, Compliance, and Medical Management

• Drive cost to serve reduction through workforce optimization, automation, and AI led interventions

• Lead U.S. healthcare transformation initiatives including digital self service, contact reduction, intelligent routing, and agent assist

• Proactively identify and mitigate operational, regulatory, and compliance risks

• Support U.S. healthcare pursuits and expansions with SME ownership for solutioning, pricing, and operating model design

• Own delivery financials including budgeting, productivity targets, and P&L performance

• Build leadership capability across Managers and Senior Managers and drive a high performance delivery culture

Qualifications:

• Bachelor’s or master’s degree in business administration or related discipline

• 13+ years BPO and contact center delivery operations

• 10+ years in U.S. healthcare contact center leadership roles

• Mandatory experience in U.S. Member Services across Commercial, Medicare, or Medicaid

• Strong exposure to Provider Services and payer back-office integration

• Hands-on experience with payer platforms such as Facets, QNXT, WGS, PEGA, and portals

• Strong knowledge of CMS audits, HEDIS, STAR ratings, and G&A processes

• Lean Six Sigma Green or Black Belt Certification preferred

Salary Range: $138,600 - $187,500 a year

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