"Alerted.org

Senior Payer Process Assessment & BPM Lead

**Category:** Business Analysis (functional and technical)

**Main location:** United States, Massachusetts, Canton

**Position ID:** J1225-1620

**Employment Type:** Full Time

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Position Description:

We are seeking a Healthcare Subject Matter Expert (SME) – Payer who brings deep expertise in payer-domain operations and processes. This individual will play a critical role in evaluating and analyzing current-state workflows across key functions such as claims, provider operations, member services, utilization management, care management, and finance.

The SME will collaborate closely with the Business Process Center of Excellence (BPCoE), process owners, analysts, and change managers to identify process gaps, improvement opportunities, compliance requirements, risks, and operational inefficiencies. By ensuring that all process assessments are accurate, industry-aligned, and reflective of real operational needs, the SME will help drive transformation initiatives that enhance efficiency and compliance within payer environments.

Ideal candidates will possess deep healthcare payer knowledge, including a thorough understanding of regulatory requirements, operational workflows, and industry best practices. They will have a proven track record of conducting comprehensive process assessments, validating accuracy and completeness, and delivering actionable insights that support strategic decision-making. This is an opportunity to leverage your domain expertise to influence enterprise-level improvements and shape the future of healthcare operations.

This position is located in our client office in Canton, MA.

Your future duties and responsibilities:

1. Process Discovery & Assessment

. Conduct current-state process assessments across payer operations.

. Facilitate process discovery sessions with business teams, process owners, and SMEs.

. Document workflows, handoffs, pain points, variations, and system dependencies.

. Identify inefficiencies, risks, compliance issues, and operational gaps.

. Assess alignment with payer regulations (CMS, NCQA, URAC, HIPAA, state-level mandates).

. Validate process inventory accuracy for payer-specific functions.

. Collaborate with cross-functional teams to ensure operational realities are captured accurately.

. Provide domain-driven insights to support transformation initiatives and compliance audits.

2. Process Documentation Support

. Provide detailed domain knowledge to enrich process maps, SIPOCs, workflow steps, and process metadata.

. Validate draft process documentation created by Analysts or Process Owners.

. Ensure payer-specific terminology, coding, clinical requirements, and compliance factors are captured accurately.

. Use templates, standards, and documentation requirements defined by the BPCoE.

. Act as a quality gatekeeper for documentation accuracy and completeness before sign-off.

3. Process Maturity & Quality Evaluation

. Evaluate processes against payer best practices and industry benchmarks.

. Identify maturity gaps (e.g., manual vs. automated steps, fragmented workflows, non-compliant areas).

. Provide input to AI Engineer and Reporting Analyst to refine quality scoring criteria.

. Recommend payer-specific quality metrics to assess process performance.

. Support development of process improvement roadmaps based on maturity assessments.

4. Process Assessments (Core Responsibility)

. Conduct end-to-end process assessments for payer operations.

. Lead or support process discovery sessions with POs/SMEs/Analysts.

. Document operational pain points, handoff issues, inefficiencies, and compliance risks.

. Identify automation potential, workflow redundancies, rework points, and failure modes.

. Ensure assessments align with strategic objectives and regulatory compliance standards.

5. Develop BPMN Process Flows (New addition per your request)

. Create detailed BPMN process maps for current-state and future-state processes.

. Ensure models reflect correct:

. roles/swimlanes

. decision points

. system interactions

. compliance checkpoints

. variations/exception flows

. Validate BPMN diagrams created by Analysts and update them based on SME knowledge.

. Prepare BPMN flows that align with BPCoE mapping standards (Level 1–5 as required).

. Provide guidance on BPMN best practices and ensure consistency across enterprise documentation.

6. Identify Gaps & Create Recommendations (Expanded per request)

. Conduct detailed gap analyses comparing current-state vs:

. payer industry best practices

. regulatory requirements

. operational performance expectations

. future-state BPCoE standards

. Provide actionable, prioritized recommendations for:

. process redesign

. efficiency gains

. compliance improvements

. automation/RPA opportunities

. documentation enhancements

. Produce gap/recommendation reports for pilot and enterprise documentation.

. Present findings and recommendations to leadership and stakeholders for decision-making.

7. Documentation Validation & Quality Assurance

. Review process documentation for accuracy, completeness, compliance alignment, and payer-specific accuracy.

. Validate that all required metadata, roles, and steps are reflected correctly.

. Partner with the AI Engineer to refine AI scoring rules based on real payer nuances.

. Ensure all BPMN and documentation follows BPCoE standards and templates.

. Maintain version control and audit readiness for all process documentation.

Required qualifications to be successful in this role:

. Deep, practical experience in payer operations such as:

o Claims processing

o Provider data management

o Auth/UM/CM workflows

o Appeals & grievances

o Enrollment & billing

o Member services

o Network operations

. Understanding of payer regulatory landscape (CMS, state regulations, NCQA, URAC).

. Serve as a domain advisor during stakeholder engagement sessions.

. Familiarity with emerging payer trends, interoperability standards, and digital health initiatives.

. Ability to interpret and apply compliance requirements to operational processes.

Process Assessment Skills

. Strong process discovery and mapping capability.

. Ability to quickly identify gaps, inefficiencies, compliance risks.

. Familiarity with Lean, Six Sigma, or BPC concepts is a plus.

. Experience conducting end-to-end process assessments and gap analyses.

. Ability to translate findings into actionable recommendations for process improvement.

Communication & Collaboration

. Ability to work with Process Owners, SMEs, Analysts, governance teams.

. Strong verbal and written communication skills.

. Ability to explain complex operations in simple terms.

. Skilled in facilitating workshops and stakeholder sessions to drive consensus.

. Ability to present findings and recommendations to senior leadership effectively.

Tools & Documentation

. Comfortable working with process maps, SIPOCs, workflows.

. Familiarity with SharePoint or similar repositories.

. Ability to review, annotate, and validate detailed documentation.

. Proficiency in BPM tools (e.g., Visio, Signavio, ARIS, or similar).

. Understanding of documentation standards and metadata requirements for enterprise process repositories.

Process Skills

. Strong expertise in BPMN modeling.

. Ability to analyze and assess complex workflows.

. Understanding of Lean or Six Sigma (preferred).

. Ability to create Level 1–5 process maps aligned with organizational standards.

Problem Solving & Analysis

. Identifying gaps, risks, root causes, inefficiencies.

. Developing practical recommendations.

. Ability to prioritize recommendations based on impact, feasibility, and compliance needs.

. Strong analytical mindset with attention to detail and operational accuracy.

Other Information:

CGI is required by law in some jurisdictions to include a reasonable estimate of the compensation range for this role. The determination of this range includes various factors not limited to skill set, level, experience, relevant training, and licensure and certifications. To support the ability to reward for merit-based performance, CGI typically does not hire individuals at or near the top of the range for their role. Compensation decisions are dependent on the facts and circumstances of each case. A reasonable estimate of the current range for this role in the U.S. is $110,800.00 - $194,000.00.

CGI's benefits are offered to eligible professionals on their first day of employment to include:

. Competitive compensation

. Comprehensive insurance options

. Matching contributions through the 401(k) plan and the share purchase plan

. Paid time off for vacation, holidays, and sick time

. Paid parental leave

. Learning opportunities and tuition assistance

. Wellness and Well-being programs

Skills:

+ Business Analysis

+ Business Process Modelling

+ Health Care Payers

What you can expect from us:

Together, as owners, let’s turn meaningful insights into action.

Life at CGI is rooted in ownership, teamwork, respect and belonging. Here, you’ll reach your full potential because…

You are invited to be an owner from day 1 as we work together to bring our Dream to life. That’s why we call ourselves CGI Partners rather than employees. We benefit from our collective success and actively shape our company’s strategy and direction.

Your work creates value. You’ll develop innovative solutions and build relationships with teammates and clients while accessing global capabilities to scale your ideas, embrace new opportunities, and benefit from expansive industry and technology expertise.

You’ll shape your career by joining a company built to grow and last. You’ll be supported by leaders who care about your health and well-being and provide you with opportunities to deepen your skills and broaden your horizons.

Come join our team—one of the largest IT and business consulting services firms in the world.

Qualified applicants will receive consideration for employment without regard to their race, ethnicity, ancestry, color, sex, religion, creed, age, national origin, citizenship status, disability, pregnancy, medical condition, military and veteran status, marital status, sexual orientation or perceived sexual orientation, gender, gender identity, and gender expression, familial status or responsibilities, reproductive health decisions, political affiliation, genetic information, height, weight, or any other legally protected status or characteristics to the extent required by applicable federal, state, and/or local laws where we do business.

CGI provides reasonable accommodations to qualified individuals with disabilities. If you need an accommodation to apply for a job in the U.S., please email the CGI U.S. Employment Compliance mailbox at [email protected] . You will need to reference the Position ID of the position in which you are interested. Your message will be routed to the appropriate recruiter who will assist you. **Please note, this email address is only to be used for those individuals who need an accommodation to apply for a job. Emails for any other reason or those that do not include a Position ID will not be returned.**

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All CGI offers of employment in the U.S. are contingent upon the ability to successfully complete a background investigation. Background investigation components can vary dependent upon specific assignment and/or level of US government security clearance held. Dependent upon role and/or federal government security clearance requirements, and in accordance with applicable laws, some background investigations may include a credit check. CGI will consider for employment qualified applicants with arrests and conviction records in accordance with all local regulations and ordinances.

CGI will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with CGI’s legal duty to furnish information.