Healthcare Payer SME

Role: Senior Healthcare Payer SME

As a Senior Healthcare Payer SME with healthcare payer experience you'll support member portals, mobile apps, and digital self-service platforms. The role focuses on gathering requirements, improving member experience, analyzing healthcare data, and delivering solutions supporting Medicaid, Medicare, claims, enrollment, and provider operations.

Location: Remote (EST) USA

Experience: Min 10+ Yrs.

Duties:

• Serve as SME for member portal, mobile app, and digital member experience platforms.
• Gather and document business requirements, user stories, and acceptance criteria.
• Lead enhancements for eligibility, benefits, claims, provider search, PCP selection, ID cards, prior authorizations, and wellness programs.
• Conduct gap analysis, process mapping, workflow analysis, and requirements traceability.
• Perform SQL-based data validation for eligibility, enrollment, provider, and claims data.
• Partner with data engineering, IT, product, and business teams to ensure data accuracy and system functionality.
• Facilitate stakeholder meetings and act as liaison between business and technical teams.
• Support Agile delivery, backlog refinement, sprint planning, and prioritization.
• Coordinate UAT, regression testing, and release validation activities.
• Ensure compliance with HIPAA, CMS, Medicaid, and other regulatory requirements.

Required:

• Bachelor's or master's degree in healthcare administration, Public Health, Nursing, or related field.
• Min 10+ years of healthcare payer experience in business/system analysis roles
• Strong understanding of Medicaid, Medicare and commercial plan operations
• Familiarity with member portals and digital health engagement platforms.
• Strong experience producing BRDs, FRDs, user stories, STTMs, business process maps, and gap analyses.

Desired:

• Experience with healthcare consumer engagement platforms.
• Knowledge of UX/UI and accessibility standards.
• Experience with digital transformation initiatives.
• Prior payer member experience projects.
• Exposure to healthcare compliance and governance programs.