Healthcare Payer Functional Lead

We are looking for an experienced Healthcare Payer Functional Lead with strong expertise in U.S. healthcare payer operations, claims adjudication, benefits administration, provider management, and payment workflows.

Key Responsibilities

• Lead end-to-end healthcare payer workflow design and process optimization.
• Translate business requirements into functional specifications, user stories, process maps, and acceptance criteria.
• Define business rules for claims processing, benefits, provider contracts, reimbursement, denials, and appeals.
• Ensure compliance with HIPAA, healthcare regulations, ANSI X12 EDI standards, and coding guidelines.
• Collaborate with product, engineering, QA, finance, compliance, and business teams.
• Drive automation, operational efficiency, and improved claims accuracy.
• Support UAT, integration testing, defect resolution, implementation, and go-live activities.

Required Skills

• Strong understanding of U.S. healthcare payer operations.
• Expertise in claims adjudication, benefits administration, and provider contracting.
• Knowledge of ANSI X12 EDI transactions: 834, 837, 835, 270/271, 276/277, and 278.
• Familiarity with HIPAA, ICD-10-CM, CPT, and HCPCS.
• Experience in functional requirements gathering, testing, and stakeholder management.

Interested candidates: Apply through LinkedIn or share your profile with our hiring team.

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