HealthRules Payer (HRP) Subject Matter Expert

Position Overview

We are seeking an experienced HealthRules Payer (HRP) Subject Matter Expert to provide functional and technical expertise in healthcare payer operations, claims adjudication, benefits configuration, pricing, enrollment, provider management, and member processing. The ideal candidate will have extensive experience resolving complex claims issues, optimizing payment operations, supporting system integrations, and leading production incident resolution. This role also requires strong knowledge of healthcare business processes, cross-functional solution design, and claims adjudication migration to HealthRules Payer.

Key Responsibilities

• Serve as the functional and technical SME for HealthRules Payer, supporting claims adjudication, benefits, pricing, enrollment, provider, and member processing.

• Analyze and resolve complex claims processing issues, including workflow bottlenecks, adjudication exceptions, reprocessing failures, and validation errors.

• Optimize claims payment operations to improve payment accuracy, processing efficiency, and timely issue resolution.

• Configure and validate HRP business rules related to benefits, reimbursement methodologies, provider contracts, pricing logic, and claims edits.

• Collaborate with Claims, Provider, Enrollment, Finance, and Compliance teams to translate business requirements into effective HRP solutions.

• Support HRP integrations and interfaces, including EDI transactions, downstream systems, payment integrity platforms, and external vendor solutions.

• Lead root-cause analysis and production incident resolution in collaboration with infrastructure, database, application, and vendor teams.

• Develop and maintain operational documentation, standard operating procedures (SOPs), process flows, and knowledge management resources.

• Support the migration of claims adjudication processes from other platforms to HealthRules Payer.

• Translate complex business and technical requirements into implementable solutions, system interfaces, and integration specifications.

• Create high-level architectural and design specifications aligned with business processes and system integration requirements.

• Partner with business stakeholders, customers, product teams, and project teams to identify requirements gaps and recommend operational improvements.

• Support business transformation initiatives by aligning business capabilities, process management, operational needs, and technology solutions.

Required Qualifications

• 10 years of relevant professional experience in healthcare payer operations, healthcare systems, or related technology and functional roles.

• Strong functional and technical expertise in HealthRules Payer (HRP).

• In-depth understanding of claims adjudication, benefits administration, pricing, enrollment, provider management, and member processing.

• Experience troubleshooting complex claims processing issues and resolving production incidents.

• Knowledge of HRP business rules, benefits configuration, reimbursement methodologies, provider contracts, pricing logic, and claims edits.

• Experience with healthcare payer integrations, EDI transactions, downstream systems, and payment integrity solutions.

• Knowledge of claims adjudication migration from legacy or alternative platforms to HealthRules Payer.

• Experience with root-cause analysis, incident management, and cross-functional technical troubleshooting.

• Ability to translate business requirements into functional specifications, technical solutions, and system integration designs.

• Strong understanding of healthcare payer business processes, operational workflows, and process improvement initiatives.

Preferred Qualifications

• Experience working with payment integrity platforms and external vendor solutions such as Cotiviti.

• Experience supporting business transformation initiatives and enterprise healthcare system implementations.

• Familiarity with architectural design, requirements analysis, operational documentation, and stakeholder solution presentations.

PRIMARY SKILLS

1. HealthRules Payer (HRP)

2. Healthcare Payer Operations

3. Claims Adjudication

4. Healthcare Provider Processes

5. Benefits Configuration and Pricing

6. Claims Processing and Payment Optimization

 SECONDARY SKILLS

1. EDI Transactions and Healthcare Integrations

2. Provider Contracts and Reimbursement Methodologies

3. Claims Migration and Platform Conversion

4. Payment Integrity

5. Root-Cause Analysis and Incident Management

6. Enrollment and Member Processing

7. Business Requirements Analysis

8. System Integration and Solution Design

9. Standard Operating Procedures (SOPs) and Process Documentation

Salary : $55 - $59