33 Payer Jobs - Page 2

Candidate should have minimum 3yrs of experience in software testing, with at least 3 years focused on User Acceptance Testing (UAT) for US Healthcare. Location - Chennai Shift - US rotational shifts Required Candidate profile Immediate Joiners OR Max 1 month notice period candidates can apply Call HR Sadiq @ 8904378561 for more details.

JD Key Responsibilities: 1. Strategic Leadership: Develop and execute a comprehensive strategy for the payer domain, focusing on member engagement, claims processing, provider relationships, and cost containment. Identify opportunities for innovation and implement solutions leveraging data analytics, AI, and automation to improve payer operations. Stay informed about industry trends, regulatory changes (e.g., CMS, ACA), and market dynamics to adapt strategies accordingly. 2. Operational Excellence: Oversee end-to-end payer operations and customer service. Ensure efficient and accurate processing of claims and reimbursement in compliance with industry standards. Drive initiatives to reduce administrative costs and improve overall operational efficiency. 3. Technology & Data Integration: Collaborate with technology teams to implement advanced platforms for claims adjudication, payment integrity, and member engagement. Leverage data analytics and predictive modeling to enhance risk management, improve care outcomes, and optimize value-based payment models. Ensure interoperability and compliance with healthcare standards such as EDI, HIPAA, and FHIR. 4. Leadership & Team Building: Build and lead high-performing teams across payer operations, technology, and analytics functions. Foster a culture of collaboration, accountability, and continuous improvement. Provide mentorship and leadership development opportunities for team members. 5. Stakeholder Management: Partner with providers, employers, brokers, and regulatory agencies to strengthen relationships and improve service delivery. Collaborate with clinical teams to align payer strategies with population health management and care delivery goals. Represent the organization at industry forums, conferences, and regulatory meetings. 6. Financial Management: Develop and oversee budgets for payer operations, ensuring cost-effectiveness and ROI. Identify opportunities to enhance revenue streams and reduce medical loss ratios (MLR). Qualifications: Bachelors degree in Healthcare Administration, Business Management, or a related field; advanced degree (MBA, MHA) strongly preferred. 25+ years of experience in leadership roles within the healthcare payer sector. Proven expertise in claims management, value-based payment models, risk adjustment, and member engagement. Strong knowledge of payer-specific regulations, including CMS, HIPAA, and ACA. Experience with technology solutions for payer operations, including claims adjudication systems, analytics platforms, and CRM tools. Exceptional strategic thinking, decision-making, and problem-solving skills. Outstanding communication and interpersonal abilities, with experience working with executive leadership and external partners. Key Competencies: Visionary leadership with a strong focus on payer transformation and innovation. Deep understanding of healthcare payer operations and regulatory environments. Skilled in financial management, including reducing administrative costs and improving MLR. Ability to lead large-scale projects and manage cross-functional teams. This role is designed for a dynamic leader who can drive transformation in the payer space while maintaining a strong focus on regulatory compliance, operational excellence, and member satisfaction.

Head Corporate Strategy is required for a global Healthcare BPO & Revenue Cycle Management (RCM) leader based in Bangalore/Chennai. This role involves working with senior leadership to drive strategic initiatives, optimize business performance, and evaluate growth opportunities. Key Responsibilities: - Develop and execute strategic initiatives to achieve business goals. - Analyze market trends, risks, and expansion opportunities. - Track key performance metrics and drive business improvements. - Build business cases and support M&A evaluations. Candidate Profile: - MBA from a Tier 1 institute with 8-12 years in corporate strategy. - 5+ years in RCM, Payer, Life sciences outsourcing is MUST for the role - Experience in the RCM industry or top management consulting firms.

Candidate should have minimum of 3 years of experience in data analysis and reporting, with at least 1 year of experience US Healthcare industry. Location - Chennai Shift - US rotational shifts Required Candidate profile Immediate Joiners OR Max 1 month notice period candidates can apply Call HR Sadiq @ 8904378561 for more details.

Candidate should have minimum 3yrs of experience in software testing, with at least 3 years focused on User Acceptance Testing (UAT) for US Healthcare. Location - Chennai Shift - US rotational shifts Required Candidate profile Immediate Joiners OR Max 1 month notice period candidates can apply Call HR Sadiq @ 8904378561 for more details.

Position : Architecture Lead Location: Chennai / Hyderabad Employment Type: Full-time Overview: The Architecture Lead in the US healthcare domain is a pivotal role responsible for designing and implementing robust, scalable, and secure technical solutions tailored to the unique needs of the healthcare industry. This role involves collaborating with cross-functional teams, ensuring compliance with industry standards, and leveraging emerging technologies to drive innovation and improve healthcare delivery. Key Responsibilities: Define the architectural vision, principles, and roadmap for healthcare solutions in alignment with business goals. Design end-to-end architectures for healthcare applications, including interoperability, data integration, and security. Ensure alignment with US healthcare regulations and standards, including HIPAA, HITECH, and FHIR. Lead the architecture design and review processes, ensuring best practices and consistency across projects. Provide technical guidance and mentorship to engineering teams, ensuring adherence to architectural guidelines. Evaluate and recommend emerging technologies, tools, and platforms to enhance healthcare solutions. Design solutions that ensure compliance with healthcare regulations and safeguard sensitive patient data. Implement robust security measures, including identity management, data encryption, and secure APIs. Stay updated on regulatory changes and adapt architectural designs accordingly. Develop architectures that enable seamless data exchange between healthcare systems, adhering to standards such as HL7 and FHIR. Collaborate with healthcare providers, payers, and third-party vendors to ensure successful system integrations. Drive initiatives to improve interoperability and support value-based care models. Lead the adoption of innovative technologies such as AI/ML, IoT, and cloud computing in healthcare applications. Solve complex technical challenges related to scalability, performance, and data analytics in the healthcare domain. Explore opportunities to modernize legacy systems and migrate to modern architectures. Work closely with business leaders, product managers, and delivery teams to ensure alignment between technical solutions and business needs. Act as a liaison between technical teams and non-technical stakeholders, effectively communicating architectural decisions. Support pre-sales efforts by contributing to technical proposals and solution presentations. Oversee the implementation of architectural solutions, ensuring high-quality deliverables within timelines and budgets. Establish governance frameworks and metrics to monitor the performance and scalability of deployed solutions. Ensure reusability of components and frameworks across multiple projects. Experiences Required: Bachelors or master’s degree in computer science, engineering, or a related field. 15+ years of experience in software architecture, with at least 5 years in the US healthcare domain. Deep knowledge of healthcare standards, protocols, and technologies (e.g., HL7, FHIR, EHRs, RCM). Proven experience in designing scalable, secure, and high-performance healthcare systems. Expertise in cloud platforms (AWS, Azure, Google Cloud) and microservices architecture. Strong understanding of DevOps practices, CI/CD pipelines, and containerization (e.g., Kubernetes, Docker). Familiarity with healthcare analytics, AI/ML, and interoperability frameworks. Preferred Skills: Experience with value-based care models and population health management. Knowledge of payer and provider ecosystems, including claims, billing, and clinical workflows. Certifications in enterprise architecture frameworks (e.g., TOGAF) or healthcare IT (e.g., CPHIMS). Key Attributes: Strategic thinker with strong problem-solving and analytical skills. Excellent communication and leadership abilities to influence and guide teams effectively. Passion for leveraging technology to improve healthcare outcomes and delivery.

Minimum Year(s) of Experience (BQ) *: US 2+ years of experience in US Health care Payer side Certification(s) Preferred: NA Required Knowledge/Skills (BQ): US Healthcare Experience Experience in Appeals & Grievances (A&G, Medicare/Medicaid) Preferred Knowledge/Skills *: Strong verbal and written communication skills, including letter writing experience. Excellent English skills with the ability to read, comprehend, write and communicate verbally with stakeholders & customers. Ability to work with firm deadlines, multi-task, set priorities and pay attention to details Ability to successfully interact with members, medical professionals, health plan and government representatives. Knowledge on Appeals & Grievances and Medicare/Medicaid Proficiency with Microsoft Word, Excel, and PowerPoint. Excellent organizational, interpersonal and time management skills. Must be detail-oriented and an enthusiastic team player. Knowledge of Pega computer system a plus. Responsibilities: As an Associate, youll work as part of a team of problem solvers with consulting and industry experience, helping our clients solve their complex member, provider and business issues. Specific responsibilities include, but are not limited to: Analyzes, evaluates and resolves member & provider appeals, disputes, grievances, and/or complaints from health plan members, providers and related outside agencies in accordance with the standards and requirements established by the Centers for Medicare and Medicaid and/or health plan. Prepares and organizes case research, notes, and documents. Contacts the member/provider through written and verbal communication. Requests, obtains and reviews medical records, notes, and/or detailed bills as appropriate. Applies contract language, benefits, and review of covered services. Conducts research, fact checking and analysis and recommends appropriate course of action and next steps for management review. Research claim / service authorization appeals and grievances using support systems to determine appeal and grievance outcomes inclusive of claims processing guidelines, provider contracts, fee schedules and system configurations to determine root cause of payment error. Determines appropriate language for letters and composes all correspondence and appeal/dispute and or grievances information concisely and accurately, in accordance with regulatory requirements. Communicates resolution to members (or authorized) representatives. Works with provider & member services to resolve balance bill issues and other member/provider complaints. Assures timeliness and appropriateness of responses per state, federal and health plan guidelines. Responsible for meeting production standards set by the department. Prepares appeal summaries, correspondence, and document findings. Include information on trends if requested. Desired Knowledge / Skills: 2+ years of experience in US Health care Payor side 1 + years of processing experience in Appeals & Grievance Denial Management Knowledge on US Health Care, Claims Adjudication, Rework & A&G Experience Level: 1+ years Shift timings: Flexible to work in night shifts (US Time zone)

Job Description:- (Mandate Requirement) Payer Side OR Member Side. Appeals & Grievances HYDERABAD ONLY NOTE* - Not looking for Provider current experience. ONLY PAYER Job Summary - A career in our Managed Services team will provide you an opportunity to collaborate with a wide array of teams to help our clients implement and operate new capabilities, achieve operational efficiencies, and harness the power of technology. Our Appeals and Grievances Managed Services (AGMS) team will provide you with the opportunity to act as an extension of our healthcare clients' business office. We specialize in appeal and grievances functions and addressing member complaints for health plans and their business partners. We leverage our clients customized workflows and associated automations in conjunction with PwC’s data advanced data analysis and quality assurance processes to enable our clients to achieve better compliant results, which ultimately allows them to provide better services to their members. Minimum Degree Required (BQ) *: Bachelor’s Degree Degree Preferred: Bachelor’s Degree Required Field(s) of Study (BQ): Any Graduation Preferred Field(s) of Study: Minimum Year(s) of Experience (BQ) *: US 2+ years of experience in US Health care Payer side Certification(s) Preferred: NA Required Knowledge/Skills (BQ): US Healthcare Experience Experience in Appeals & Grievances (A&G, Medicare/Medicaid) Preferred Knowledge/Skills *: Strong verbal and written communication skills, including letter writing experience. Excellent English skills with the ability to read, comprehend, write and communicate verbally with stakeholders & customers. Ability to work with firm deadlines, multi-task, set priorities and pay attention to details Ability to successfully interact with members, medical professionals, health plan and government representatives. Knowledge on Appeals & Grievances and Medicare/Medicaid Proficiency with Microsoft Word, Excel, and PowerPoint. Excellent organizational, interpersonal and time management skills. Must be detail-oriented and an enthusiastic team player. Knowledge of Pega computer system a plus. Responsibilities: As an Associate, you’ll work as part of a team of problem solvers with consulting and industry experience, helping our clients solve their complex member, provider and business issues. Specific responsibilities include, but are not limited to: Analyzes, evaluates and resolves member & provider appeals, disputes, grievances, and/or complaints from health plan members, providers and related outside agencies in accordance with the standards and requirements established by the Centers for Medicare and Medicaid and/or health plan. Prepares and organizes case research, notes, and documents. Contacts the member/provider through written and verbal communication. Requests, obtains and reviews medical records, notes, and/or detailed bills as appropriate. Applies contract language, benefits, and review of covered services. Conducts research, fact checking and analysis and recommends appropriate course of action and next steps for management review. Research claim / service authorization appeals and grievances using support systems to determine appeal and grievance outcomes inclusive of claims processing guidelines, provider contracts, fee schedules and system configurations to determine root cause of payment error. Determines appropriate language for letters and composes all correspondence and appeal/dispute and or grievances information concisely and accurately, in accordance with regulatory requirements. Communicates resolution to members (or authorized) representatives. Works with provider & member services to resolve balance bill issues and other member/provider complaints. Assures timeliness and appropriateness of responses per state, federal and health plan guidelines. Responsible for meeting production standards set by the department. Prepares appeal summaries, correspondence, and document findings. Include information on trends if requested. Desired Knowledge / Skills: 2+ years of experience in US Health care Payer side 1 + years of processing experience in Appeals & Grievance Denial Management Knowledge on US Health Care, Claims Adjudication, Rework & A&G Experience Level: 1+ years Shift timings: Flexible to work in night shifts (US Time zone)