Job Summary

Play the role of Claims Domain lead for MMIS health care projects. Drive the claims module and process, domain knowledge, performs analysis of business requirements, designs and develops documentation, ensures quality process, coordinates with customers. Works in a team environment and guides the entire life cycle. Responsible for meeting customer expectations, troubleshooting problems in the application, and assisting customers in implementation decisions.

Qualification:

1. Candidate should have strong healthcare domain experience and should have good knowledge of Medicaid and Medicare.
2. Candidate should have hands-on experience in claims processing and adjudication processes.
3. Must have good experience in Reference code/data sets required in claims adjudication
4. Must have prior experience or understanding in configuring benefits or programs in the claims system across various sub-systems.
5. Should be able to run queries and perform basic system analysis, RCA, etc,
6. Should work closely with the client and development team during the stages of development, and conduct demos at completion of milestones, track and close feedback from such demos.
7. Must have excellent written and spoken communication skills. Should be able to multitask between the internal team and clients based on priority tasks.
8. Work closely with Dev, architecture, and Design teams to define the GUI view and platform requirements, which are the foundation of the product.
9. In-depth understanding of Claims and Claims lifecycle:- Member- Provider- Claim submission – Paper and EDI X12- Adjudication- Payment Cycle (Finance)- Reporting
10. Claim Types:- Professional- Dental- Institutional- Pharmacy- Encounters and Capitation
11. Claim Formats:- EDI X12 formats like 837P/I/D- X12 formats 835, 834, 270/271, 276/277
12. Claim System:- Familiarity with systems like CMdS, GHS, Facets, etc.
Technical Skills- SQL: To validate data in backend tables (e.g., claim status, payment details, findmembers/providers, Benefit Plan).
EDI Tools: Validating X12 files.- Interface Testing: Understanding how data flows between systems and formats, and using tools like Postman.

Preferred skills:- Minimum of 8+ years of experience in healthcare experience especially in the MMIS domain.- Capability to think out of the box to create new solutions as needed.- Ability to validate Test scenarios and test plans, test data.- Should be able to review requirements, documentation, and create a Requirements Traceability matrix (RTM)- Should have excellent communication (written and spoken ) skills to engage with different stakeholders like QA/dev team, clients, and end users of Clients and Business Units.- Ability to assess current functionality available in a product vis-à-vis market trends, regulatory requirements to be implemented in future versions of the product.- Ability to drive and share the requirements with Technical and Architects regarding product features to be implemented.- Communication: Collaborate with cross-functional teams