HealthRules Payer SME

Location

: Canton, MA

Experience

: 10 - 20 Years

Apply By

: 21st December 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