Heathcare-SME

About us

At R Systems we are shaping the future of technology by designing cutting-edge software #products, platforms, and #digital experiences that drive business growth for our clients.

Our product mindset and advanced engineering capabilities in #Cloud, Data, #AI, and Customer Experience empower us to deliver innovative solutions to key players across the high-tech industry. This includes ISVs, SaaS, and Internet companies, as well as leading organizations in #telecom, #media, #healthcare, #finance, and #manufacturing.

We are Great Place To Work Certified in 10 countries where we have a full-time workforce - India, the USA, Canada, Poland, Romania, Moldova, Indonesia, Singapore, Malaysia, and Thailand.

We are looking to hire an experienced Subject Matter Expert (SME) on the US payer side to provide in-depth knowledge, strategic insights, and guidance to our teams. Candidate needs be an expert in U.S. healthcare insurance, including private insurers, Medicaid, Medicare, and other payer models.

Job Title- Healthcare-SME

Job Location- Noida/Pune

Exp- 15+ Yrs.

Key Responsibilities:

1. Payer Expertise:
2. Understanding of U.S. Healthcare Payer Models:
3. Private Health Insurance - Comprehensive understanding of private insurance models like:
4. HMOs, PPOs, EPOs, POS plans
5. Commercial insurance plans offered by employers or individual markets.
6. Premium and cost-sharing structures including copayments, deductibles, and out-of-pocket maximums.
7. Government Payer Programs: Good understanding in government-funded healthcare programs like Medicare (Parts A, B, C, D), Medicaid, Childrens Health Insurance Program (CHIP), Tricare and VA (Veterans Affairs)
8. Dual Eligibles
9. Payment Models and Reimbursement Mechanisms
10. Fee-for-Service (FFS) Models
11. Capitation & Value-Based Care: Understanding of value-based care models like Bundled Payments, Accountable Care Organizations (ACOs), Pay-for-Performance, Capitated Payments
12. Good Understanding of Quality Measurement and Metrics in Value Based Care like HEDIS, NCQA, PCMH, MIPS
13. Risk-sharing Models- HCC model for Medicare or CCM model for Medicaid
14. Good understanding of Care Coordination models & Patient-Centered Care models
15. Contract Negotiations & Payer-Provider Relations like Contracting Knowledge, Payer-Provider Dispute Resolution, Managed Care Agreements

16 Regulatory and Compliance Knowledge of CMS, ACA, HIPSS, State Specific Payer Regulations

17 Claims Processing & Payment Operations:

1. Handling EDI formats for Eligibility, Pre-Authorization, 837P/I/D, 999, 276, 277, 835
2. Claims Lifecycle, handling of Medical, Pharmacy, Dental, Vision and Behavioural Health Claims
3. Coding Systems: Strong working knowledge of ICD-10, CPT, HCPCS, Revenue Codes and DRG coding for inpatient billing
4. Claims Denial Management
5. Payment Integrity and Fraud Prevention
6. Payer Trends & Emerging Models like SDOH. Predictive Analytics, HSAs, High-Deductible Plans