New 
Healthrules Payer Sme
 Tata Consultancy Services | |
$120,000 - $145,000
| |
sick time, 401(k)
| |
 United States, Massachusetts, Canton | |
 Oct 28, 2026 | |
|
Job Description
Must-Have Technical/Functional Skills l Serve as the functional and technical subject-matter expert for the payer platform, providing expertise in claims adjudication, benefits, pricing, enrollment, provider, and member processing. l Analyze and resolve complex claims-processing issues, including claims stuck in workflow, adjudication exceptions, reprocessing failures, and validation errors. l Optimize payer-platform payment-cycle operations to improve claims-payment accuracy and enable timely issue identification and resolution. l Possess a good understanding of the configuration and validation of payer-platform business rules, including benefits, reimbursement methodologies, provider contracts, pricing logic, and claims edits. l Partner with Claims, Provider, Enrollment, Finance, and Compliance teams to translate business requirements into payer-platform solutions and process improvements. l Support payer-platform integrations and interfaces, including EDI transactions, downstream systems, payment-integrity platforms, and external vendor solutions. l Lead root-cause analysis and incident resolution for production issues, coordinating with infrastructure, database, application, and vendor teams. l Improve operational documentation, standard operating procedures, process flows, and knowledge assets. l Possess good knowledge of migrating claims adjudication from other platforms to the payer platform. Roles & Responsibilities l Demonstrate in-depth knowledge of payer-side healthcare operations and expertise in payer platforms. l Collaborate with key stakeholders to translate business and technical requirements and issues into implementable products and solutions with the necessary technical interfaces and integrations. l Create high-level architecture and design specifications focused on system integration and alignment with business processes. l Partner with customers to present business and technical solutions for complex functionality and cross-functional issues. l Work closely with product and project teams to review and analyze requirements, identify gaps, present operational solutions, and surface client needs to product teams. l Lead business-transformation initiatives by aligning business-capability models with value streams. l Integrate strategic business needs, process management, operations, and systems to deliver comprehensive solutions Salary Range: $120,000-$145,000 a year TCS Employee Benefits Summary: Discretionary Annual Incentive. Comprehensive Medical Coverage: Medical & Health, Dental & Vision, Disability Planning & Insurance, Pet Insurance Plans. Family Support: Maternal & Parental Leaves. Insurance Options: Auto & Home Insurance, Identity Theft Protection. Convenience & Professional Growth: Commuter Benefits & Certification & amp; Training Reimbursement. Time Off: Vacation, Time Off, Sick Leave & Holidays. Legal & Financial Assistance: Legal Assistance, 401K Plan, Performance Bonus, College Fund, Student Loan Refinancing. #LI-SP1
Location
Canton, MA
Function
TECHNOLOGY
Role
Process Expert
ID
437106
Skills
Healthcare
Salary Range
$120,000 - $145,000 Desired Candidate Profile
Qualifications BACHELOR OF COMPUTER SCIENCE | |