Opportunity snapshot: 

Reporting to the Capability Lead Claims within the Capability Modernisation Program the Pega Business Architect will have expertise in the Pega Smart Claims Solution. This role will be responsible for configuring and managing claims rules within the Pega Smart Claims platform, aligning claims management processes with business goals and regulatory requirements. The role will work closely with cross-functional teams, including claims operations, technology, and compliance, to streamline and automate claims processing, ensuring accuracy, efficiency, and enhanced customer & provider experiences. 

This role will have strong business analysis skills and a deep understanding of health insurance claims to make a significant impact on Bupa’s claims transformation journey. 

Your Contribution:

Claims Rules Configuration in Pega Smart Claims Solution 

• Configure and maintain claims rules in Pega Smart Claims, including eligibility, adjudication, benefits, payments, and denials.
• Collaborate with operations and IT teams to align workflows with business goals.
• Optimize decision logic to enhance automation and reduce manual processes.
• Support testing and validation of claims rules for accuracy and functionality.

Business Analysis & Requirements Gathering 

• Collaborate with stakeholders to understand requirements, customer needs, and regulatory updates.
• Document business requirements, user stories, and process flows for claims management.
• Analyze processes and recommend solutions to automate claims, reduce errors, and improve efficiency.
• Advise on best practices for claims management within Pega Smart Claims

Stakeholder Collaboration and Communication 

• Bridge business and IT teams to ensure configurations align with requirements.
• Facilitate cross-functional meetings to review progress and address concerns.
• Support business teams in managing claims rules within Pega.
• Train users on Pega Smart Claims functionalities for smooth adoption.

Optimisation and Continuous Improvement 

• Lead efforts to enhance claims processing efficiency by optimizing Pega rules.
• Identify and address bottlenecks, recommending improvements to systems or processes.
• Implement stakeholder feedback to align claims rules with business goals.
• Develop and deploy automated decision-making to increase speed and reduce costs.

Regulatory Compliance and Risk Management 

• Ensure claims rules comply with Australian healthcare regulations, including the Private Health Insurance Act and APRA standards.
• Stay updated on regulatory changes to maintain compliance in Pega Smart Claims configurations.
• Work with compliance and legal teams to adapt claims rules to evolving requirements.

Quality Assurance & Testing 

• Design test cases to validate Pega Smart Claims rules meet business requirements.
• Collaborate with QA teams on system, integration, and UAT testing for claims configurations.
• Ensure thorough testing of new rules, focusing on edge cases and compliance.
• Manage defect resolution with IT teams to address issues promptly

Performance Monitoring & Reporting 

• Monitor claims performance, identifying trends in accuracy, processing time, and user experience.
• Develop dashboards and KPIs to track claims rule effectiveness and resolution times.
• Collaborate with data teams to provide insights for decision-making and operational improvements.

Training & Support 

• Offer ongoing training and support to claims and operations teams on Pega Smart Claims.
• Create user manuals, training materials, and documentation for effective system use.
• Provide expert-level support for troubleshooting claims-related issues in Pega.

Qualifications, training & Experience

• 4+ years of relevant Pega Decisioning experience. 
• Pega Decisioning project experience through all phases of the project lifecycle from scoping and planning, requirements gathering, design, development, testing, and go live. 
• Pega Decisioning certification. 
• Bachelor’s Degree or equivalent professional experience 
• Minimum of 5 years of experience in business architecture, business analysis, or claims management within the health insurance sector. 
• Proven experience working with Pega Smart Claims Solution or similar Pega platforms, with hands-on experience in configuring claims rules and workflows. 
• Strong understanding of health insurance claims processes, including policy eligibility, benefits, claim adjudication, payments, and denials. 
• Solid knowledge of Australian health insurance regulations, such as the Private Health Insurance Act, APRA, and other relevant standards. 
• Experience in business process automation, workflow design, and process optimization within claims management systems. 
• Proficiency in documenting business requirements, functional specifications, and user stories. 
• Strong problem-solving skills and the ability to analyse and address complex business challenges. 
• Excellent communication and interpersonal skills, with the ability to collaborate effectively with technical and non-technical teams. 
• Strong understanding of agile methodologies and experience working in an agile environment. 
• Familiarity with Agile and Scrum development practices. 
• Experience in health insurance industry compliance and regulatory frameworks. 
• Experience with user acceptance testing (UAT) and system deployment. 
• Knowledge of reporting and data analytics tools to assess claims processing performance. 

What’s in it for me?

As well as a competitive salary, a range of Bupa benefits and flexible working/work from home arrangements, you’ll be challenged and encouraged to innovate. You will partner with colleagues who are dedicated to delivering exceptional experiences. We respect and consider everyone, knowing your difference will make the difference. 

Perk highlights:

• Discount on our health insurance, travel, car, home, contents, and pet insurance products as well as discounts when you attend a Bupa Dental clinic or purchase glasses from a Bupa Optical store.
• A dedicated internal wellbeing team provides you with a range of services, such as a global resilience program, regular training opportunities on a range of wellbeing topics and access to a variety of wellbeing discounts. 
• An additional well-being day each year to treat yourself. 

About Bupa

Bupa is an international healthcare group which has been committed to a purpose of longer, healthier, happier lives and making a better world for more than 70 years. In Australia and New Zealand, Bupa supports more than 5 million customers through a broad range of health and care services including health insurance, aged care, rehabilitation, dental, optical, medical, hearing, and medical visa services. 

Our people reflect the diversity of our community.  At Bupa, your wellbeing, identity, and own story is respected and valued.

Apply now and become an integral part of our innovative and dynamic team!