Healthrules Payer (Hrp) SME

Talent Software Services, Inc.biddeford pool, ME

$57 - $61 / hour

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Overview

Remote

On-site

Compensation

$57-$61/hour

Job Description

JobDescription:HealthRulesPayer(HRP)SME

JobTitle:HealthRulesPayerSME
Location:RockyHill,Connecticut/Canton,Maine
Duration:6months
ExperienceRequired:10+years
Domain:HealthcarePayer
PrimarySkills:HealthRulesPayer(HRP),ClaimsAdjudication,HealthcarePayerOperations,BusinessProcessOptimization

Must-HaveTechnical/FunctionalSkills

ExtensiveexperiencewithHealthRulesPayer(HRP)asafunctionalandtechnicalSubjectMatterExpert(SME).
Strongknowledgeofhealthcarepayeroperationsandclaimsprocessing.
Expertiseinclaimsadjudication,benefitsadministration,pricing,enrollment,providerprocessing,andmemberprocessing.
Experiencetroubleshootingcomplexclaimsprocessingissues,includingworkflowfailures,adjudicationexceptions,reprocessingfailures,andvalidationerrors.
KnowledgeofHRPpaymentcycleoperationsandclaimspaymentoptimization.
ExperienceconfiguringandvalidatingHRPbusinessrules.
Understandingofbenefitsconfiguration,reimbursementmethodologies,providercontracts,pricinglogic,andclaimsedits.
AbilitytotranslatebusinessrequirementsintoHRPconfigurationsandprocessimprovements.
ExperiencewithEDItransactions,systeminterfaces,anddownstreamintegrations.
Knowledgeofpaymentintegrityplatformsandexternalvendorintegrations,includingCotiviti.
Experiencewithproductionincidentmanagementandroot-causeanalysis.
KnowledgeofclaimsadjudicationmigrationfromlegacyplatformstoHealthRulesPayer.
Strongdocumentationskills,includingSOPs,processflows,andtechnicalspecifications.

RolesandResponsibilities

1.HealthRulesPayerFunctionalandTechnicalExpertise

ServeasthefunctionalandtechnicalSMEforHealthRulesPayer.
Provideexpertiseinclaimsadjudication,benefits,pricing,enrollment,provider,andmemberprocessing.
GuidebusinessandtechnicalteamsonHRPcapabilities,configurations,andbestpractices.
AnalyzecomplexbusinessrequirementsandrecommendappropriateHRPsolutions.
EnsureHRPfunctionalityalignswithhealthcarepayerbusinessprocesses.

2.ClaimsProcessingandAdjudication

Analyzeandresolvecomplexclaimsprocessingissues.
Troubleshootclaimsstuckinworkflows,adjudicationexceptions,reprocessingfailures,andvalidationerrors.
Investigateclaimsprocessingdiscrepanciesanddetermineappropriateresolutions.
Supportaccurateandtimelyclaimsadjudicationandpayment.
Identifyopportunitiestoimproveclaimsprocessingefficiencyandoperationalperformance.

3.PaymentCycleOptimization

OptimizeHealthRulesPayerpaymentcycleoperations.
Improveclaimspaymentaccuracyandprocessingefficiency.
Identifyrecurringpaymentissuesandimplementcorrectiveactions.
Improvethetimelyidentificationandresolutionofclaimsprocessingerrors.
Collaboratewithbusinessandtechnicalteamstostreamlinepaymentworkflows.

4.HRPBusinessRulesandConfiguration

ConfigureandvalidateHRPbusinessrulesaccordingtobusinessrequirements.
Supportbenefitsconfigurationandreimbursementmethodologies.
Reviewprovidercontracts,pricinglogic,andclaimsedits.
Validateclaimsadjudicationrulesandpaymentcalculations.
Identifyconfigurationgapsandrecommendimprovements.
Ensurebusinessrulessupportaccurateandcompliantclaimsprocessing.

5.BusinessandStakeholderCollaboration

PartnerwithClaims,Provider,Enrollment,Finance,andComplianceteams.
TranslatebusinessandtechnicalrequirementsintoimplementableHRPsolutions.
Collaboratewithstakeholderstoresolvecross-functionalissues.
Presentbusinessandtechnicalsolutionsforcomplexfunctionalities.
Workwithcustomerstounderstandoperationalchallengesandrecommendprocessimprovements.
Communicatetechnicaldependencies,risks,andimplementationrequirements.

6.IntegrationsandInterfaces

SupportHRPintegrationsandsysteminterfaces.
WorkwithElectronicDataInterchange(EDI)transactionsanddownstreamsystems.
SupportintegrationswithpaymentintegrityplatformsandexternalvendorssuchasCotiviti.
Analyzeinterfacefailuresanddatavalidationissues.
Coordinatewithapplication,database,infrastructure,andvendorteamstoresolveintegrationproblems.
Ensureinterfacessupportaccurateandtimelydataexchangeacrosshealthcaresystems.

7.ProductionSupportandRoot-CauseAnalysis

Leadroot-causeanalysisforproductionincidentsandclaimsprocessingfailures.
Investigaterecurringsystemissuesanddeterminecorrectiveactions.
Coordinateincidentresolutionwithinfrastructure,database,application,andvendorteams.
Supportproductiontroubleshootingandissueprioritization.
Developpreventivemeasurestoreducerecurringincidents.
Maintaindocumentationofincidents,resolutions,andtechnicalfindings.

8.ClaimsMigrationandTransformation

SupportmigrationofclaimsadjudicationprocessesfromlegacyplatformstoHealthRulesPayer.
Analyzeexistingclaimsprocessingsystemsandidentifymigrationrequirements.
Assessbusinessrules,claimsworkflows,pricingconfigurations,andintegrationdependencies.
IdentifygapsbetweenlegacyplatformsandHRPfunctionality.
Supportmigrationplanning,validation,andpost-migrationissueresolution.
Helpensurecontinuityandaccuracyofclaimsprocessingduringplatformtransitions.

9.Architecture,Design,andDocumentation

Createhigh-levelarchitecturalanddesignspecifications.
Developsolutiondesignsfocusedonsystemintegrationandbusinessprocessalignment.
Prepareoperationaldocumentation,SOPs,processflows,andknowledgeassets.
Reviewbusinessandtechnicalrequirementsandidentifyfunctionalgaps.
MaintaindocumentationofHRPconfigurations,workflows,interfaces,andoperationalprocedures.
Supportknowledgesharingandcontinuousprocessimprovement.

10.BusinessTransformationandProcessImprovement

Leadbusinesstransformationinitiativesalignedwithorganizationalobjectives.
Alignbusinesscapabilitymodelswithvaluestreams.
Integratestrategicbusinessneeds,processmanagement,operations,andsystems.
Collaboratewithproductandprojectteamstoreviewrequirementsandidentifygaps.
Communicateclientneedsandoperationalchallengestoproductteams.
Recommendcomprehensivesolutionstoimprovehealthcarepayeroperations.

IdealCandidateProfile

Healthcarepayerprofessionalwith10+yearsofrelevantexperienceandstrongHealthRulesPayerexpertise.
Provenabilitytotroubleshootcomplexclaimsadjudicationandpaymentprocessingissues.
StrongunderstandingofHRPconfiguration,benefits,pricing,providercontracts,andreimbursementrules.
ExperiencewithEDIintegrations,paymentintegrityplatforms,andproductionsupport.
KnowledgeoflegacyclaimsplatformmigrationtoHealthRulesPayer.
Strongbusinessanalysis,solutiondesign,documentation,andstakeholdermanagementskills.
Abilitytobridgebusinessoperationsandtechnicalteamstodelivereffectivehealthcarepayersolutions.

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FAQs About Healthrules Payer (Hrp) SME Jobs at Talent Software Services, Inc.

What is the work location for this position at Talent Software Services, Inc.?

This job at Talent Software Services, Inc. is located in biddeford pool, ME, according to the details provided by the employer. Some roles may also include multiple work locations depending on the requirement.

What pay range can candidates expect for this role at Talent Software Services, Inc.?

Candidates can expect a pay range of $56.81–$60.6 per hour for this role.

What employment applies to this position at Talent Software Services, Inc.?

The employer has not provided this information. This may be discussed during the hiring process.

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