EmblemHealth

Senior Process & Performance Optimization Specialist

EmblemHealth • $110K — $130K *
New York, NY 10025In-Person
Healthcare
Less than 5 years of experience
Today
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Job Overview by Ladders

Qualifications

  • Bachelor's Degree required
  • 4-6+ years in healthcare payer operations or management consulting with a focus on operational performance improvement
  • Experience leading process improvement or optimization initiatives
  • Proven track record of managing multiple projects from inception to completion independently
  • Strong knowledge of healthcare operations workflows, including dependencies
  • Experience collaborating with vendors and offshore teams
  • Excellent analytical and problem-solving skills, with a focus on data interpretation.

Responsibilities

  • Drive execution of operational initiatives from start to finish
  • Structure work efforts with clear objectives and milestones
  • Develop detailed project plans using tools like Excel or Jira
  • Engage stakeholders across various teams to align objectives
  • Identify and resolve execution risks proactively
  • Validate operational improvements against success criteria
  • Document processes and optimize workflows based on analysis.

Benefits

  • Opportunity for high levels of autonomy in work efforts
  • Collaborative environment with cross-functional teams
  • Potential for direct impact on operational efficiency
  • Access to advanced analytical tools and methodologies
  • Supportive of professional growth and skill development opportunities.
Full Job Description
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 12 Claims 12 Appeals 12 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

About EmblemHealth

EmblemHealth is a non-profit health insurance company based in New York City. It is one of the largest non-profit health insurers in the United States, serving over 3 million people. EmblemHealth offers a range of health insurance plans, including HMO, PPO, and EPO plans, as well as Medicare and Medicaid plans. The company also offers wellness programs and disease management services. EmblemHealth was formed in 2006 through the merger of Group Health Incorporated (GHI) and the Health Insurance Plan of Greater New York (HIP). The company has offices in New York City and Albany, New York.
Learn more about EmblemHealth
Size
3,000 employees
Industry
Healthcare
Net Income
-$100 million
Founded
2006
5 Year Trend
-5%
Revenue
$10 billion
NASDAQ
* Ladders Estimates

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