HealthRules Payer SME — Claims & Benefits Expert

TechClub Inc; Massachusetts; Vor Ort; USD 150.000 - 190.000; Vollzeit

Zusammenfassung

TechClub Inc. is seeking an experienced HealthRules Payer (HRP) Subject Matter Expert (SME) in Canton, MA to lead complex claims processing and HRP configurations across multi-disciplinary teams.

The role emphasizes maintaining high performance in claims adjudication, enrollment, and payment integrity with enterprise systems integration. The successful candidate will translate business requirements into HRP configurations, drive process improvements, and collaborate with Claims, Enrollment,

Qualifikationen

• 10+ years of experience in healthcare payer operations, claims processing, and enterprise healthcare systems.
• Strong functional and technical expertise in HealthRules Payer (HRP).
• Experience with claims adjudication, benefits configuration, pricing logic, enrollment, and member processing.

Aufgaben

• 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 workflow, adjudication exceptions, reprocessing, and validation issues.
• Optimize claims payment cycle operations to improve payment accuracy and efficiency.
• Configure and validate HRP business rules related to benefits, provider contracts, reimbursement methodologies, pricing logic, claims edits, and payment policies.
• Collaborate with Claims, Provider Management, Enrollment, Finance, Compliance, and IT teams to translate requirements into HRP configurations and solutions.
• Support HRP integrations and interfaces, including EDI transactions and external vendors such as Cotiviti.
• Lead root-cause analysis and incident resolution for production issues across teams.
• Develop and maintain high-level solution designs, functional specs, and system integration requirements.

Kenntnisse

HealthRules Payer

Claims Adjudication

Benefits Configuration

Claims Operations

System Integrations

Tools

Cotiviti

EDI Transactions

Jobbeschreibung

TechClub Inc. is seeking an experienced HealthRules Payer (HRP) Subject Matter Expert (SME) in Canton, MA to lead complex claims processing and HRP configurations across multi-disciplinary teams.

The role emphasizes maintaining high performance in claims adjudication, enrollment, and payment integrity with enterprise systems integration. The successful candidate will translate business requirements into HRP configurations, drive process improvements, and collaborate with Claims, Enrollment,