This is a fully remote position, open to applicants in United States.

📋 Description

• Lead the claims module and processes while offering domain expertise.

• Conduct analysis of business requirements.

• Create and develop documentation, ensuring a quality process in collaboration with customers.

• Work collaboratively in a team setting, providing guidance throughout the entire lifecycle.

• Accountable for meeting customer expectations and resolving application issues.

• Support customers in making implementation decisions.

⛳️ Requirements

• Extensive experience in the health care domain, with solid knowledge of Medicaid and Medicare.

• Practical experience in claims processing and adjudication procedures.

• Proficient in reference codes and data sets necessary for claims adjudication.

• Prior experience or familiarity with configuring benefits or programs within claims systems across various subsystems.

• Capability to execute queries and perform basic system analysis (e.g., RCA).

• Strong collaboration with clients and development teams during the development phases, conducting demonstrations upon milestone completion, and managing feedback from these demos.

• Exceptional written and verbal communication abilities, with multitasking skills based on task priorities.

• Collaboration with Development, Architecture, and Design teams to outline GUI views and platform requirements.

• Thorough understanding of claims and the claims lifecycle, including Member, Provider, Claim submission (both Paper and EDI X12), Adjudication, Payment Cycle (Finance), and Reporting.

• Familiarity with EDI X12 formats and systems such as CMdS, GHS, and Facets.

• Proficient in SQL for validating data in backend tables and checking X12 files.

• Knowledge of Interface Testing and data flow between systems.