The role of SPE Claims HC focuses on analyzing and supporting healthcare product solutions within payer EDI environments ensuring accurate and efficient handling of electronic claims and related transactions. The candidate will contribute to improving claims processing workflows enhancing data quality and supporting stakeholders through precise documentation and communication in English while working in a hybrid day shift model.

Responsibilities

Analyze healthcare product specifications and claims processing rules to ensure that payer EDI transactions are implemented accurately and conform to organizational standards and industry regulations
Support end to end lifecycle of healthcare claims within payer EDI systems by monitoring transaction flows and identifying data or configuration issues that impact timely adjudication
Collaborate with cross functional teams to translate business requirements from healthcare stakeholders into clear and testable functional specifications for EDI payer solutions
Coordinate with technology and operations teams to validate that changes to healthcare products and claims rules are correctly implemented and do not introduce defects in EDI payer processes
Conduct detailed root cause analysis for issues in healthcare claims and payer EDI transactions and document findings to enable sustainable corrective actions and knowledge reuse
Perform structured testing of healthcare product changes and EDI payer enhancements by preparing test scenarios data sets and expected results that reflect real world claim situations
Provide concise and accurate documentation for healthcare products payer EDI workflows and claims handling procedures to support knowledge transfer and operational continuity
Communicate clearly in English with internal stakeholders to present analysis outcomes status updates and recommendations that improve transparency of claims processing activities
Recommend improvements to claims processing and EDI payer workflows by using insights from defect patterns turnaround times and data quality metrics to enhance efficiency and member outcomes
Support compliance alignment by validating that healthcare product configurations and payer EDI transactions adhere to relevant standards and organizational controls related to privacy and data integrity
Assist in incident and defect management by tracking reported issues prioritizing remediation actions and verifying that fixes to claims and EDI payer logic are effective before deployment
Contribute to the hybrid work environment by maintaining consistent productivity collaboration and timely communication using digital tools while operating primarily in day shift with no travel requirements
Utilize knowledge of commercial claims when applicable to compare process variations and propose reusable patterns that strengthen claims management practices across multiple lines of business

Qualifications

Demonstrate practical experience in healthcare products by applying understanding of benefit structures claim rules and policy configurations to support reliable claims processing
Apply working knowledge of EDI payer domain concepts by handling transaction sets data elements and business rules that govern electronic claims and related administrative exchanges
Use familiarity with commercial claims as a helpful asset when analyzing scenarios that involve different funding arrangements coverage types and adjudication methods within claims environments
Communicate fluently in English through reading writing and speaking to ensure that requirements documentation defect descriptions and stakeholder interactions are precise and easy to understand
Operate effectively within a hybrid work model by managing time self organization and collaboration tools to meet delivery expectations while working primarily in a day shift schedule
Adapt prior industry or project experience of two to four years to new healthcare and payer EDI contexts by quickly learning system nuances and applying structured problem solving methods

Certifications Required

Recommended certifications include Certified Professional in Healthcare Information and Management Systems or equivalent healthcare IT credential.