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Job Description: Health Business Architect – Payer Domain

Role Overview

We are seeking a seasoned Business Architect with deep experience in the health insurance (payer) domain and hands-on expertise with Health technologies. The candidate will serve as a strategic consulting partner to business and IT, own the end-to-end business architecture, and lead the design and delivery of health business-enabled capabilities across claims, benefits, provider, and member operations.

Key Responsibilities

Leads end to end business architecture development across core healthcare payer functions such as claims, enrolment, provider network, care management, UM/CM, and billing.
Aligns business strategy, technology solutions, and operating models to enable enterprise transformation.
Develops capability models, value streams, future state process designs, and target operating models to guide modernization initiatives.
Conducts current state assessments, identifies operational and system gaps, and recommends improvements to drive efficiency, compliance, and member/provider experience.
Partners closely with product, IT, clinical and operations teams to design and support digital transformation and platform implementations.
Acts as a bridge between business stakeholders and technical teams, translating requirements into functional designs and ensuring solution alignment.
Builds strategic roadmaps, business cases, and value realization plans to articulate benefits and investment priorities.
Ensures alignment with regulatory requirements such as CMS, HIPAA, NCQA, HEDIS, and payer compliance standards.
Supports change management, communication, and adoption planning to ensure smooth rollout of new processes and systems.
Facilitates executive-level presentations, strategic discussions, and decision support for transformation initiatives.

Required Qualifications

8–12+ years of experience in the healthcare payer domain, with a strong consulting background leading large scale business and technology transformation initiatives.
Deep understanding of payer core administration platforms (e.g., HealthEdge, Facets, QNXT, Health Rules, Javelina, or similar technologies), with experience in solution design, business architecture, configuration oversight, or product leadership.
Strong functional expertise across key payer operations, including claims processing, benefit/product modeling, provider data management, pricing & payment integrity, accumulators, enrollment & membership, and customer service workflows.
Demonstrated ability to lead executive and SME workshops, facilitate requirement discovery, and produce high quality deliverables such as process maps, capability models, business architecture blueprints, and transformation roadmaps.
Comprehensive understanding of regulatory and compliance requirements, including HIPAA, CMS mandates, Medicare/Medicaid policies, and state specific payer regulations.
Excellent communication, stakeholder management, and documentation skills, with the ability to translate complex business needs into technology aligned solutions and effectively bridge business and IT teams.
Proven experience working in agile environments, including participation in PI planning, backlog refinement, user story creation, acceptance criteria definition, and leadership of UAT cycles.

Preferred Qualifications

Experience working across multiple health plan types—including national and regional commercial plans, Medicare Advantage, Medicaid, and employer group plans—with a proven track record of supporting successful system deployments and go lives.
Exposure to leading healthcare payer and care management platforms such as HealthEdge Source (payment integrity), GuidingCare (care management), Wellframe (member engagement), and industry standard provider data management solutions.
Knowledge of integrations involving CRM platforms (e.g., Salesforce), enterprise data ecosystems (EDW, Lakehouse), clearinghouses, PBMs, utilization management systems, and other ecosystem interfaces commonly used in payer environments.
Professional certifications such as AHIP, or product specific training/certifications on market leading payer platforms (e.g., HealthEdge, Facets, QNXT, or similar), demonstrating strong domain and solution expertise.
savings, provider data accuracy, and member NPS; drive continuous improvement.

Education

Bachelor's or Master's degree in Business, Healthcare Administration, Information Systems, or related field.

Location & Work Model

Preferred location: Open to onshore/offshore hybrid model; ability to travel for key workshops and go-live support as needed.

Equal Opportunity Employer

We are an equal opportunity employer and value diversity. All employment is decided based on qualifications, merit, and business need.

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BC sector health-Senior-Health Business Architect