HealthRules Payer SME

Role: HealthRules Payer SME

Location: Onsite at Canton, MA

Position Type: Contract

Skills:

• Serve as the functional and technical SME for HealthRules Payer (HRP), providing expertise on claims adjudication, benefits, pricing, enrollment, provider, and member processing.
• Analyze and resolve complex claims processing issues, including claims stuck in workflow, adjudication exceptions, reprocessing failures, and validation errors.
• Optimize HRP payment cycle operations, improving accurate claims payment and optimizing timely issue identification and resolution.
• Should posses good understanding of configuration and validation of HRP business rules, including benefits, reimbursement methodologies, provider contracts, pricing logic, and claims edits.
• Ability to partner with Claims, Provider, Enrollment, Finance, and Compliance teams to translate business requirements into HRP solutions and process improvements.
• Support HRP integrations and interfaces, including EDI transactions, downstream systems, payment integrity platforms, and external vendor solutions such as Cotiviti.
• Lead root-cause analysis and incident resolution for production issues, coordinating with infrastructure, database, application, and vendor teams.
• Improve operational documentation, SOPs, process flows, and knowledge assets.
• 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.