(PCS) to support healthcare payer product configuration, benefit design, and system implementation activities. The ideal candidate should have strong knowledge of healthcare payer processes, product and benefit configuration, claims lifecycle, and experience working with business and technical teams in an Agile delivery environment.
Key Responsibilities
Configure and manage healthcare insurance products, benefits, plans, and rules using Pega PCS.
Work closely with business stakeholders, SMEs, product owners, and technical teams to understand product requirements and translate them into PCS configurations.
Support analysis, design, build, validation, and implementation of healthcare payer products within the PCS platform.
Review benefit structures, plan designs, riders, limits, accumulators, cost shares, exclusions, and eligibility rules.
Participate in requirement discussions, grooming sessions, design reviews, sprint planning, and daily stand-ups.
Ensure PCS configurations align with business rules, regulatory requirements, and downstream system needs.
Support integration discussions between PCS and claims, enrollment, provider, billing, and downstream adjudication systems.
Perform configuration unit testing and support QA/UAT teams during validation cycles.
Identify configuration defects, perform root cause analysis, and coordinate resolution with relevant teams.
Prepare and maintain functional specifications, configuration documents, mapping documents, test scenarios, and traceability artifacts.
Collaborate with Pega architects, developers, business analysts, testers, and client SMEs to ensure timely and quality delivery.
Support migration, release management, and deployment activities related to PCS configurations.
Provide subject matter expertise on PCS best practices and healthcare payer product implementation.
Required Skills & Experience
Strong hands-on knowledge of Pega PCS / Pega Product Composer System.
Experience in healthcare payer domain, preferably with product, benefit, plan, and group configuration.
Understanding of healthcare insurance concepts such as:
o Benefit plans
o Medical, pharmacy, dental, or vision benefits
o Copay, coinsurance, deductible, out-of-pocket maximum
o Accumulators
o Eligibility rules
o Networks and provider tiers
o Claims adjudication rules
Ability to analyze product requirements and convert them into PCS configuration specifications.
Experience working with Agile/Scrum delivery teams.
Strong analytical, problem-solving, and communication skills.
Ability to collaborate with business SMEs, technical teams, QA teams, and project leadership.
Good understanding of end-to-end healthcare payer processes including enrollment, product setup, benefits, claims, and member/provider servicing.
Experience in defect triage, issue resolution, and configuration validation.
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