Sr Healthcare Payer SME - REMOTE
We are seeking a highly experienced and driven Senior Healthcare Consultant to join our team. The ideal candidate will be a Subject Matter Expert (SME) in healthcare with a strong background in claims processing, population health, backend operations, and clinical leadership. This role also requires experience in AI-driven healthcare solutions, member engagement strategies, and member portal optimization to enhance patient experience and health outcomes. Responsibilities:- Healthcare SME Leadership: • Serve as a subject matter expert across healthcare domains including payer operations, clinical workflows, and regulatory compliance. • Provide clinical leadership and guidance to internal teams and clients. Requirements Gathering & Documentation: • Collaborate with stakeholders to elicit business and functional requirements. • Create comprehensive Business Requirement Documents (BRDs) and Functional Requirement Documents (FRDs). Claims & Backend Process Expertise: • Analyze and optimize claims processing workflows. • Identify and resolve backend operational inefficiencies. Population Health Management: • Design and support population health strategies including risk stratification, care coordination, and quality improvement. • Leverage data to drive insights and improve patient outcomes. HEDIS Improvement Strategies: • Assess current HEDIS performance and identify gaps. • Recommend and implement strategies to enhance HEDIS scores and compliance. AI & Data Analytics Integration: • Apply AI and machine learning techniques to healthcare data for predictive analytics, risk modeling, and operational insights. • Collaborate with data science teams to develop and deploy AI solutions that support clinical and business objectives. Member Engagement & Portal Optimization: • Develop and implement strategies to improve member engagement through digital tools and personalized outreach. • Collaborate with product and IT teams to enhance member portal functionality, usability, and adoption. • Use analytics to monitor member behavior and identify opportunities for improved engagement and satisfaction. Market Research & Strategic Insights: • Conduct active market research to identify trends, opportunities, and competitive benchmarks. • Translate research findings into strategic recommendations for clients and internal teams. Health Coaching & Clinical Advocacy: • Act as a health coach to support patient engagement and behavior change. • Advocate for evidence-based practices and patient-centered care models. Experience:- 10+Years Location:- Remote / EST hours Educational Qualifications: - • Bachelor's or Master's degree in Healthcare Administration, Public Health, Nursing, or related field. • Technical certification in multiple technologies is desirable. Mandatory skills • 8+ years of experience in healthcare consulting or related roles. • Proven expertise in claims processing, population health, HEDIS, and member engagement. • Experience with AI tools and platforms used in healthcare (e.g., predictive analytics, NLP, machine learning). • Familiarity with member portals and digital health engagement platforms. • Strong analytical, documentation, and communication skills. • Ability to work cross-functionally with clinical, technical, and business teams. Preferred Skills: • Certification in Health Coaching or Clinical Leadership. • Familiarity with NCQA, CMS, and other regulatory bodies. • Experience with payer-provider collaboration models. • Exposure to AI/ML platforms such as Python, R, or cloud-based analytics tools (Azure, AWS, Google Cloud Platform). Apply tot his job