US Healthcare SME (Payer Side)

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At R Systems, we are shaping the future of technology by designing cutting-edge software products, platforms, and digital experiences that drive business growth for our clients.

Our product mindset and advanced engineering capabilities in Cloud, Data, AI, and Customer Experience empower us to deliver innovative solutions to key players across the high-tech industry. This includes ISVs, SaaS, and Internet companies, as well as leading organizations in telecom, media, healthcare, finance, and manufacturing.

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Experienced Subject Matter Expert (SME) on the US payer side to provide in-depth knowledge, strategic insights, and guidance to our teams. Candidate needs be an expert in U.S. healthcare insurance, including private insurers, Medicaid, Medicare, and other payer models.

Key Responsibilities:

1. Payer Expertise:

• Understanding of U.S. Healthcare Payer Models:

Private Health Insurance - Comprehensive understanding of private insurance models like:

HMOs, PPOs, EPOs, POS plans.

• Government Payer Programs: Medicare (Parts A, B, C, D), Medicaid, Children’s Health Insurance Program (CHIP), Tricare and VA (Veterans Affairs)
• Dual Eligibles

2. Payment Models and Reimbursement Mechanisms

• Fee-for-Service (FFS) Models
• Capitation & Value-Based Care:
• Good Understanding of Quality Measurement and Metrics in Value Based Care like HEDIS, NCQA, PCMH, MIPS
• Risk-sharing Models- HCC model for Medicare or CCM model for Medicaid

Regulatory and Compliance Knowledge of CMS, ACA, HIPSS, State Specific Payer Regulations

3.Claims Processing & Payment Operations:

• Handling EDI formats for Eligibility, Pre-Authorization, 837P/I/D, 999, 276, 277, 835
• Claims Lifecycle, handling of Medical, Pharmacy, Dental, Vision and Behavioral Health Claims
• Coding Systems: Strong working knowledge of ICD-10, CPT, HCPCS, Revenue Codes and DRG coding for inpatient billing
• Claims Denial Management
• Payment Integrity and Fraud Prevention

4.Payer Trends & Emerging Models like SDOH. Predictive Analytics, HSAs, High-Deductible Plans