1. Incident Intake & Identification
- Oversee the intake protocol for incidents identified both internally (Research, Audit, QA) and externally by clients.
- Ensure all incidents are formally logged in the work queue with critical data points, including concept numbers, policy information, and verbatim client communications.
- Serve as the primary point of contact for client-facing teams to authorize incident creation on behalf of customers.
2. Triage & Scoping
- Review intake forms to concept out false positives and validate legitimate incidents.
- Conduct deep-dive research to determine the impact scope: whether an issue is isolated to a single concept or affects an entire project hierarchy.
- Engage external dependencies, such as Policy Owners or Data Teams, for expert review when specialized policy knowledge is required.
3. Prioritization & Classification
- Categorize incidents based on nature:
- Logical Incidents: Issues impacting logic, claims, or dollar value (Priority: High/Critical).
- Editorial Incidents: Non-functional text or formatting issues (Priority: Standard).
- Manage “Turn Off” features for concepts to prevent unauthorized execution during an active incident.
4. Communication & Approval Management
- Secure mandatory approvals before applying production fixes to avoid disrupting active executions.
- For Client Concepts: Draft “Change Impact Summaries” and secure client consent regarding potential impacts on active claims.
- For Library Concepts: Route approval requests to internal Domain Leads to ensure updates remain compliant with overarching policy intent.
5. Resolution & Continuous Improvement
- Manage the conversion of Incident Tickets into full “Projects” for complex systemic corrections.
- Lead Post Incident Root Cause Analysis (RCA) using frameworks like the “3 Ps” (Product, Process, People), Fishbone diagrams, FMEA and other tools.
- Document and implement Corrective and Preventive Actions (CAPA) to reduce the recurrence of similar failure modes.
- Maintain the Daily Incident Resolution Tracker to provide leadership with visibility into resolution speed and incident trends.
Required Skills & Qualifications
- US Healthcare: Experienced working in Payment Integrity business and strong knowledge of the P.I.
- Certifications: Industry relevant certifications in Coding, Insurance, Healthcare domains, Six Sigma
- Analytical Mindset: Ability to perform complex scoping to understand the true breadth of an issue across multiple tables and concepts.
- Process Governance: Experience managing a structured SOP with sequential phases, from qualification to incident closure.
- Communication: Ability to provide “Impact Transparency” to stakeholders and preserve the exact nuance of client complaints.
- Technical Familiarity: Understanding of concept development cycles and the ability to distinguish between “Error Workflows” and “Incident Workflows”.
- Collaboration Work closely with cross functional teams( engineering,data,content etc) to resolve and initiate preventive mechanisms.
Scope of Impact
This role applies to all teams involved in Concept Creation, Maintenance, Research, Configuration, and Quality Assurance. Success is measured by the ability to minimize client impact through rapid correction and the implementation of a robust preventive mechanism.