Healthcare Claims Integration Consultant

Healthcare Claims Integration Consultant (Dual Claims – Aetna / Medicare / Medicaid)
Location: Remote (USA)

Overview

We are seeking a highly experienced Healthcare Claims Integration Consultant to support a strategic healthcare initiative focused on dual claims processing, payer integration, and cost optimization in collaboration with Aetna and related healthcare programs.

This role is critical to supporting a large-scale healthcare transformation involving Medicare and Medicaid coordination, dual claims strategy, and payer operational alignment.

The consultant will work closely with executive leadership (CIO/President level stakeholders) to design and implement a scalable approach for claims integration and cost efficiency.

Key Responsibilities

Lead design and advisory for dual claims strategy and integration frameworks
Support healthcare payer alignment involving Aetna, Medicare, and Medicaid
Analyze and optimize claims workflows, coordination of benefits (COB), and adjudication processes
Define and recommend operating models for cost reduction and claims efficiency
Collaborate with executive stakeholders to translate business needs into technical and operational solutions
Evaluate current-state claims processes and identify gaps, risks, and integration opportunities
Provide advisory support for payer integration during acquisition or organizational transition
Guide implementation strategy for claims data exchange and interoperability
Support development of roadmaps, governance models, and execution plans
Required Experience

10+ years in healthcare payer/claims domain
Strong expertise in claims processing, adjudication, and payer operations
Hands-on experience with dual claims / coordination of benefits (COB)
Exposure to Medicare and Medicaid programs and regulatory frameworks
Experience working with or alongside Aetna or similar large national payers
Strong understanding of healthcare cost structures and reimbursement models
Experience in payer integration, healthcare transformation, or acquisition support
Ability to engage with CIO, VP, and executive-level stakeholders
Preferred Experience

Healthcare consulting background (Big 4 or boutique healthcare advisory)
Experience with claims platforms, payer systems, or healthcare data integration
Familiarity with EDI transactions (837/835), HIPAA compliance
Experience in large-scale payer modernization programs
Soft Skills

Strong executive communication and stakeholder management
Strategic thinking with ability to operate in ambiguous environments
Ability to bridge business, clinical, and technical teams
Problem-solving mindset with focus on measurable cost impact