Title: Healthcare Payor Provider Domain Functional Lead
Location: Remote
Contract & Full time
The Healthcare Payor Provider Domain Functional Lead serves as a subject-matter expert and strategic liaison between business stakeholders and delivery teams, ensuring successful design and execution of healthcare solutions across payer and provider domains. The role drives functional strategy, business transformation, regulatory compliance, and operational alignment across end-to-end healthcare workflows.
This position requires deep experience in both healthcare payor (claims, enrollment, utilization management, value-based care) and healthcare provider (clinical operations, revenue cycle, EHR/EMR) landscapes, with the ability to translate business needs into scalable functional and technology solutions.
Key Responsibilities
Domain Leadership & Strategy
- Act as the functional domain lead for healthcare payor and provider initiatives.
- Define and own end-to-end business workflows spanning payor provider interactions.
- Provide thought leadership on industry trends, including value-based care, interoperability (FHIR), payer-provider data exchange, and consumer-driven healthcare.
- Advise leadership on operating models, transformation roadmaps, and best practices.
Business Analysis & Functional Design
- Lead functional discovery sessions and requirements gathering with senior stakeholders.
- Translate business requirements into functional specifications, business rules, and process flows.
- Define use cases, acceptance criteria, and success metrics.
- Ensure alignment across clinical, financial, operational, and compliance requirements.
Payor Domain Expertise
- Claims adjudication, pricing, and payment integrity
- Enrollment, eligibility, and benefits administration
- Prior authorization and utilization management
- HEDIS, Star Ratings, risk adjustment (HCC)
- Value-based care models, capitation, shared savings
- Regulatory compliance (CMS, HIPAA, ACA)
Provider Domain Expertise
- Clinical workflows and care delivery models
- Revenue Cycle Management (RCM): front-end, coding, billing, collections
- EHR/EMR systems (Epic, Cerner, Meditech)
- Clinical documentation improvement (CDI)
- Quality reporting and population health
- Provider performance and contract management
Cross-Functional Collaboration
- Partner with technology, data, operations, and compliance teams.
- Work closely with architects and developers to ensure functional accuracy.
- Support testing teams with UAT planning and execution.
- Coordinate with change management and training teams.
Program & Stakeholder Management
- Serve as a trusted advisor to executive and senior business stakeholders.
- Support large transformation and modernization programs.
- Identify risks, dependencies, and mitigation strategies.
- Ensure timely delivery with high functional quality.
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