Position Overview: We are looking for a US Healthcare Data Integration SME to support our Payment Integrity client onboarding and operations in the US Healthcare domain. The role involves comprehensive understanding of EDI, Healthcare Claim Form (Professional - 1500), (Facility - 1450), EDI maps for ANSI X12 transaction sets to claims model, Client claims data mapping, Data specs management, Data transformation, Data integration support, Data integrity validating, Data classification and Managing healthcare data from multiple sources to ensure accurate claims analysis, audit processes, and payment accuracy and support client onboarding.
Specialty Expertise:
Candidates must have proficiency in the following areas:
- Understanding of Revenue Cycle Management (RCM), US healthcare Claims & coding and billing.
- Healthcare Claim Form (Professional - 1500), (Facility - 1450) and EDI maps for ANSI X12 transaction sets.
- Medical Codes: CPT/HCPCS, ICD, DRG, Modifiers etc.
- Provider Data: NPI, Taxonomy Codes across all providers.
- Value sets: Standard value set in US healthcare.
- Data Integrity Validation.
- Data classification Metholodologies.
- Preferable, Clinical Data Exchange – Understanding expertise in healthcare data exchange standards (HL7, FHIR,) and clinical terminologies (SNOMED, LOINC).
Key Responsibilities:
- EDI and Interoperability Leadership: Serve as the Subject Matter Expert (SME) for Electronic Data Interchange (EDI) and healthcare interoperability. Lead the full Software Development/Implementation/Onboarding Lifecycle (SDLC) for cross-functional projects, including requirements gathering, design, testing, implementation, and post-production support.
- HIPAA X12 Specialization: Specialize in HIPAA-compliant X12 transactions, with a strong focus on the 837 (Healthcare Claim File), to support payment integrity operations, data workflows, and payer-provider or payer-payer data mapping and integration.
- Data Specification Management: Design, develop, and maintain robust data claims model/Data Specification for healthcare claims and payment integrity systems for proof of concepts and Go-live.
- Data Sourcing and Transformation: Integrate data from multiple sources, including claims systems, payer platforms, and external healthcare datasets. Perform essential data mapping, transformation, and validation to ensure data accuracy and consistency.
- Collaboration and Alignment: Partner closely with technical teams, business analysts, and client teams to ensure regulatory compliance, seamless system integration, and process automation. Work with Payment Integrity, Analytics, and Technology teams to support audit and automation initiatives.
- Operational Excellence & Compliance: Monitor ETL processes and troubleshoot integration issues. Ensure strict compliance with HIPAA and data security standards when handling sensitive healthcare data. Act as the primary Data Integration liaison between Client and internal teams, driving timely resolution, system compliance, and stakeholder alignment.
Team Development & Mentorship:
- Trained and mentored junior analysts, supporting team professional development and enhancing performance.
- Developed onboarding guides and mentoring programs to support team expansion and knowledge retention.
- Co-develop automated tools with IT to correct transaction errors in real-time, eliminating multi-week delays.
- Collaborated with developers and cross-functional teams to enhance workflow efficiency and optimize system integration.
Client Communication: Data Integration
- Communicate effectively with clients to address and resolve data-related queries independently.
- Analyze and interpret client-reported data issues and provide appropriate solutions.
- Assist clients in ensuring smooth and accurate data integration processes.
- Proactively coordinate with clients to clarify requirements and maintain efficient data workflows.
Requirements:
- Strong understanding of US Healthcare data and claims processing workflows.
- Experience working with healthcare claims datasets and payer systems.
- ANSI X12 transaction sets.
- Claims Model mapping (EDI to Claims Model).
- Understanding of medical coding systems including CPT, HCPCS, ICD, and modifiers.
- Familiarity with dataset policies and rules such as Medicare and Medicaid guidelines, preferable.
- Familiarity of standard healthcare value set, schema etc.
- Experience in data mapping, transformation logic, and integration documentation.
- Ability to analyze data requirements and translate them into data or business rules.
- Strong attention to data accuracy, consistency, and validation.
- Ability to collaborate effectively with cross-functional teams in a fast-paced environment.
- Strong analytical and problem-solving skills.
Qualifications:
Education & Certification (one of the following required):
- Medical or Life Sciences background (MBBS, BDS, BPT, BAMS, Nursing, Pharmacy, Life Sciences)
Certification Requirements:
- Preferable:
- FHIR/HL7, EDI Certification
- Certified Health Data Analyst (CHDA)
Experience:
- Experience in US Healthcare Data Integration (SME), US Healthcare Data Analysis with deep understanding of Claims model, EDI 837, X12, US healthcare Codesets and datasets.
Key Skills:.
- Healthcare Claims Data Analysis.
- Payment Integrity and Claims Adjudication Domain Knowledge.
- Knowledge of code sets: CPT, HCPCS, ICD, DRG, PCS, Modifiers.
- Understanding of Healthcare Claim Form (Professional - 1500), (Facility - 1450) and EDI maps for ANSI X12 transaction sets.
Work Location: Jayanagar - Bangalore.
Work Mode: Work from Office.
