HealthRules Payer SME

Job Title: HealthRules Payer SME
Location: Canton, MA
Domain: Healthcare Payer / Health Insurance

Required Expertise: HealthRules Payer (HRP), Claims Adjudication, Benefits Configuration, Claims Operations, System Integrations

Job Overview

We are seeking an experienced HealthRules Payer (HRP) Subject Matter Expert (SME) with 10+ years of experience in healthcare payer operations, claims processing, and enterprise healthcare systems. The ideal candidate will possess strong functional and technical expertise in HealthRules Payer, including claims adjudication, benefits configuration, provider contracts, reimbursement methodologies, pricing logic, enrollment, and member processing.

The candidate will be responsible for resolving complex claims processing issues, optimizing claims payment operations, supporting system integrations, leading production incident resolution, and driving process improvements. This role requires close collaboration with Claims, Provider Management, Enrollment, Finance, Compliance, IT, and external vendor teams to deliver effective, scalable, and compliant healthcare payer solutions.

Key Responsibilities

• Serve as the functional and technical SME for HealthRules Payer (HRP), providing expertise across claims adjudication, benefits, pricing, enrollment, provider management, and member processing.
• Analyze, troubleshoot, and resolve complex claims processing issues, including claims stuck in workflow, adjudication exceptions, reprocessing failures, configuration errors, and validation issues.
• Optimize claims payment cycle operations to improve payment accuracy, operational efficiency, timely issue identification, and resolution.
• Configure, analyze, and validate HRP business rules related to benefits, reimbursement methodologies, provider contracts, pricing logic, claims edits, and payment policies.
• Partner with Claims, Provider Management, Enrollment, Finance, Compliance, and business operations teams to translate business requirements into HRP configurations, functional solutions, and process improvements.
• Support HRP integrations and interfaces, including EDI transactions, downstream applications, payment integrity platforms, and external vendor solutions such as Cotiviti.
• Lead root-cause analysis and incident resolution for production issues, collaborating with infrastructure, database, application support, development, and vendor teams.
• Support claims adjudication migration from legacy or alternative claims processing platforms to HealthRules Payer, including requirements analysis, mapping, configuration validation, testing, reconciliation, and production readiness.
• Develop and maintain high-level solution designs, functional specifications, system integration requirements, process flows, and technical documentation.
• Review business and technical requirements, identify functional gaps and dependencies, and recommend operational and system-level solutions.
• Collaborate with product owners, project managers, architects, and technical teams to ensure solutions align with business processes, operational objectives, and system architecture.
• Lead or support business transformation initiatives by aligning business capabilities, operational processes, value streams, and technology solutions.
• Establish and maintain standard operating procedures (SOPs), troubleshooting guides, knowledge articles, process documentation, and operational support materials.
• Support system testing, integration testing, regression testing, user acceptance testing (UAT), defect triage, and business sign-off.
• Monitor claims processing performance, identify recurring issues, recommend corrective actions, and implement continuous improvement initiatives.
• Present functional and technical solutions to stakeholders and customers, explaining complex issues, resolution approaches, risks, and recommendations.

Required Technical and Functional Skills

• 10+ years of relevant experience in healthcare payer systems, claims processing, healthcare IT, or related functional and technical roles.
• Strong hands-on functional and technical expertise in HealthRules Payer (HRP).
• In-depth understanding of healthcare payer operations, including claims lifecycle management, claims adjudication, benefits administration, provider management, enrollment, and member processing.
• Experience troubleshooting complex claims issues, adjudication failures, workflow exceptions, claims reprocessing, and payment discrepancies.
• Strong understanding of HRP configuration and validation of benefit plans, provider contracts, reimbursement methodologies, pricing rules, and claims edits.
• Experience optimizing claims payment operations, payment accuracy, claims turnaround time, and exception resolution.
• Knowledge of healthcare EDI transactions and payer integrations, including relevant HIPAA transaction standards such as 837, 835, 834, and 270/271.
• Experience supporting interfaces between HRP, downstream applications, payment integrity systems, financial systems, and external vendors such as Cotiviti.
• Strong root-cause analysis, incident management, production support, and problem-solving skills.
• Experience with claims adjudication migration from legacy or alternative platforms to HealthRules Payer.
• Ability to translate business and technical requirements into functional specifications, configuration requirements, integration designs, and implementable solutions.
• Experience creating process flows, solution documentation, SOPs, troubleshooting guides, and operational knowledge assets.
• Strong stakeholder management and communication skills, with the ability to collaborate across business, technical, operations, and vendor teams.

Preferred Qualifications

• Experience with healthcare claims platforms, payer administration systems, or large-scale claims transformation programs.
• Familiarity with payment integrity solutions and vendor integrations, including Cotiviti.
• Experience with claims conversion, data mapping, claims reconciliation, parallel testing, and production cutover.
• Understanding of HIPAA compliance, healthcare data standards, payer policies, and claims-related regulatory requirements.
• Experience with SQL or database querying for claims analysis, reconciliation, data validation, and issue investigation.
• Familiarity with incident management, change management, release management, and production support processes.
• Experience working in Agile, Waterfall, or hybrid delivery environments.
• Strong analytical, documentation, presentation, and cross-functional problem-solving skills.

Roles and Responsibilities

• Demonstrate in-depth knowledge of healthcare payer operations and HealthRules Payer functionality.
• Translate business needs and technical issues into implementable HRP solutions, configurations, and integration requirements.
• Develop and review high-level architectural and functional designs, ensuring alignment with business processes and enterprise systems.
• Partner with customers and stakeholders to resolve complex functional issues and present business and technical solution options.
• Work with product and project teams to analyze requirements, identify gaps, assess dependencies, and communicate operational needs.
• Drive business transformation and continuous improvement initiatives by aligning business capabilities, value streams, processes, and technology.
• Coordinate with development, infrastructure, database, testing, and vendor teams to ensure timely resolution of production issues.
• Support end-to-end implementation, migration, testing, deployment, and stabilization of HealthRules Payer solutions.

Key Skills Summary

HealthRules Payer (HRP) | Healthcare Payer Operations | Claims Adjudication | Claims Processing | Benefits Configuration | Provider Contracts | Pricing and Reimbursement Methodologies | Claims Edits | Enrollment and Member Management | Claims Payment Optimization | EDI Transactions | HIPAA | Cotiviti | System Integration | Claims Migration | Root-Cause Analysis | Production Support | SQL | Data Validation | Claims Reconciliation | Functional Specifications | Solution Design | UAT | Process Improvement | SOPs | Stakeholder Management