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:

1. Serve as a subject matter expert across healthcare domains including payer operations, clinical workflows, and regulatory compliance.
2. Provide clinical leadership and guidance to internal teams and clients.

Requirements Gathering & Documentation:

1. Collaborate with stakeholders to elicit business and functional requirements.
2. Create comprehensive Business Requirement Documents (BRDs) and Functional Requirement Documents (FRDs).

Claims & Backend Process Expertise:

1. Analyze and optimize claims processing workflows.
2. Identify and resolve backend operational inefficiencies.

Population Health Management:

1. Design and support population health strategies including risk stratification, care coordination, and quality improvement.
2. Leverage data to drive insights and improve patient outcomes.

HEDIS Improvement Strategies:

1. Assess current HEDIS performance and identify gaps.
2. Recommend and implement strategies to enhance HEDIS scores and compliance.

AI & Data Analytics Integration:

1. Apply AI and machine learning techniques to healthcare data for predictive analytics, risk modeling, and operational insights.
2. Collaborate with data science teams to develop and deploy AI solutions that support clinical and business objectives.

Member Engagement & Portal Optimization:

1. Develop and implement strategies to improve member engagement through digital tools and personalized outreach.
2. Collaborate with product and IT teams to enhance member portal functionality, usability, and adoption.
3. Use analytics to monitor member behavior and identify opportunities for improved engagement and satisfaction.

Market Research & Strategic Insights:

1. Conduct active market research to identify trends, opportunities, and competitive benchmarks.
2. Translate research findings into strategic recommendations for clients and internal teams.

Health Coaching & Clinical Advocacy:

1. Act as a health coach to support patient engagement and behavior change.
2. 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).