Healthrules Payer Sme

Tata Consultancy Services; Canton (MA); On-site; USD 120,000 - 145,000; Full time

Benefits offered by this job

Discretionary Annual Incentive

Commuter Benefits

Certification & Training Reimbursement

Medical Coverage — Health Plan

Dental & Vision Coverage

401K Plan

Job summary

Tata Consultancy Services Limited in Canton, MA, is seeking a Process Expert to serve as the functional and technical subject-matter expert for the payer platform, covering claims adjudication, benefits, pricing, enrollment, provider and member processing.

You will collaborate with Claims, Provider and Finance teams to translate business requirements into payer-platform solutions, optimize payment-cycle operations, and lead root-cause analysis for production issues, while contributing to

Qualifications

• In-depth knowledge of payer-side healthcare operations and payer platforms.
• Experience translating business and technical requirements into implementable solutions.
• Ability to design system integration interfaces and architecture.

Responsibilities

• Demonstrate in-depth knowledge of payer-side healthcare operations and payer platforms.
• Collaborate with stakeholders to translate requirements into implementable products and technical interfaces.
• Create high-level architecture and design specifications focused on system integration.
• Partner with customers to present business and technical solutions for complex functionality.
• Work with product and project teams to analyze requirements and surface client needs.

Skills

Healthcare

Education

Bachelor of Computer Science

Job description

Job Description

Must-Have Technical/Functional Skills

• Serve as the functional and technical subject-matter expert for the payer platform, providing expertise in 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 payer-platform payment-cycle operations to improve claims-payment accuracy and enable timely issue identification and resolution.
• Possess a good understanding of the configuration and validation of payer-platform business rules, including benefits, reimbursement methodologies, provider contracts, pricing logic, and claims edits.
• Partner with Claims, Provider, Enrollment, Finance, and Compliance teams to translate business requirements into payer-platform solutions and process improvements.
• Support payer-platform integrations and interfaces, including EDI transactions, downstream systems, payment-integrity platforms, and external vendor solutions.
• Lead root-cause analysis and incident resolution for production issues, coordinating with infrastructure, database, application, and vendor teams.
• Improve operational documentation, standard operating procedures, process flows, and knowledge assets.
• Possess good knowledge of migrating claims adjudication from other platforms to the payer platform.

Roles & Responsibilities

• Demonstrate in-depth knowledge of payer-side healthcare operations and expertise in payer platforms.
• Collaborate with key stakeholders to translate business and technical requirements and issues into implementable products and solutions with the necessary technical interfaces and integrations.
• Create high-level architecture and design specifications focused on system integration and alignment with business processes.
• Partner with customers to present business and technical solutions for complex functionality and cross-functional issues.
• Work closely with product and project teams to review and analyze requirements, identify gaps, 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

Salary Range: $120,000-$145,000 a year

TCS Employee Benefits Summary:

• Discretionary Annual Incentive.
• Comprehensive Medical Coverage: Medical & Health, Dental & Vision, Disability Planning & Insurance, Pet Insurance Plans.
• Family Support: Maternal & Parental Leaves.
• Insurance Options: Auto & Home Insurance, Identity Theft Protection.
• Convenience & Professional Growth: Commuter Benefits & Certification & Training Reimbursement.
• Time Off: Vacation, Time Off, Sick Leave & Holidays.
• Legal & Financial Assistance: Legal Assistance, 401K Plan, Performance Bonus, College Fund, Student Loan Refinancing.

#LI-SP1

Location

Canton, MA

Function

TECHNOLOGY

Role

Process Expert

ID

437106

Skills

Healthcare

Salary Range

$120,000 - $145,000

Desired Candidate Profile

Qualifications

BACHELOR OF COMPUTER SCIENCE