HealthRules Payer SME

Position: HealthRules Payer SME

Location: Canton, MA (Onsite)

Duration: 8+ months

Description:

Must Have Technical/Functional Skills:

1. Serve as the functional and technical SME for HealthRules Payer (HRP), providing expertise on claims adjudication, benefits, pricing, enrolment, provider, and member processing.

2. Analyse and resolve complex claims processing issues, including claims stuck in workflow, adjudication exceptions, reprocessing failures, and validation errors.

3. Optimize HRP payment cycle operations, improving accurate claims payment and optimizing timely issue identification and resolution

4. Should possess good understanding of configuration and validation of HRP business rules, including benefits, reimbursement methodologies, provider contracts, pricing logic, and claims edits.

5. Ability to partner with Claims, Provider, Enrolment, Finance, and Compliance teams to translate business requirements into HRP solutions and process improvements.

6. Support HRP integrations and interfaces, including EDI transactions, downstream systems, payment integrity platforms, and external vendor solutions such as Cotiviti.

7. Lead root-cause analysis and incident resolution for production issues, coordinating with infrastructure, database, application, and vendor teams.

8. Improve operational documentation, SOPs, process flows, and knowledge assets

9. Possessing good knowledge of migration of claims adjudication from other platforms to HRP

Roles & Responsibilities:

· Demonstrate in-depth knowledge around payer-side healthcare operations, with expertise in Healthrules Payer.

· Collaborate with key stakeholders to translate business and technical requirements/ issues into implementable products and solutions with necessary technical interfaces and integrations.

· Create high-level architectural and design specifications with a focus on system integration and alignment with business processes.

· Partner with customers to present business and technical solutions for complex functionalities/ cross functional issues

· Work closely with product and project teams to review and analyze requirements, identify gaps to present operational solutions and surface client needs to product teams.

· Lead business transformation initiatives by aligning business capability models with value streams.

· Integrate strategic business needs, process management, operations, and systems to deliver comprehensive solutions

Education: At least a bachelor’s degree (or equivalent experience) in Computer Science, Software/Electronics Engineering, Information Systems, or closely related field is required.