HealthEdge

Claims Specialist

• Be responsible for processing assigned claims based on client-specified guidelines or as directed by the team leader
• Be responsible for meeting productivity targets, financial and procedural accuracy standards as established by management
• Mentor junior members of the team
• Collaborate with other team members on special projects as assigned by the team leads; special projects can include process documentation development, training, quality audits, assisting with surge activity for the client(s), or any other project as determined by the team leader
• Knowledge base around physician practices and hospital coding, billing and medical terminology, CPT, HCPCS, and ICD-10, UB04, CMS 1500, authorizations, medical terminology, and concepts of healthcare
• Establish and maintain an appropriate level of communication with management to address issues and concerns and take preventive measures that ensure processing accuracy and quality

Claims Processor

Compliance

• Monitor, interpret, and track CMS guidance affecting Medicare Advantage and Medicaid programs
• Communicate state and federal requirements to clients
• Oversee the organization of regulatory distribution process
• Develop desk level procedures, presentations, and training materials

Regulatory Compliance Analyst

Security Engineer

• Contribute to developing and communicating a strategic vision for global security architecture
• Help design and implement comprehensive security architectures encompassing network security, application security, data protection, and identity management
• Identifying and assessing security risks and developing mitigation strategies
• Evaluate and implement advanced security technologies and solutions
• Leverage automation throughout technology stack to ensure best practices with Identity and Access management
• Build bridges throughout the organization, leading with education and building influence

Information Security Architect

Manager

• Directly manage a team of Business Consultants, providing day-to-day leadership, guidance, and performance oversight
• Ensure all team members have a clear understanding of client business objectives and the implementation plans in place to achieve them
• Oversee the successful, on-time, and on-budget delivery of software implementation and expansion projects, maintaining a high standard of quality and client satisfaction throughout
• Drive operational efficiency across project delivery by developing and enforcing consistent processes, methodologies, and best practices
• Monitor project timelines, budgets, and resource allocation; identify and address risks before they impact delivery outcomes
• Serve as a strategic partner to client stakeholders and internal Client Operations and Customer Success leaders, ensuring alignment on objectives, priorities, and delivery status throughout the engagement lifecycle
• Act as a primary escalation point for client issues; proactively manage risks and lead corrective action planning with a client-first mindset
• Lead scoping, sizing, and estimating efforts for assigned engagements, and manage competing priorities across the project portfolio
• Coach customers on HealthEdge best practices and advocate for client needs internally to drive the best possible outcomes
• Collaborate cross-functionally with Sales, Product, Customer Success, and other internal teams to ensure alignment on client objectives and delivery requirements
• Provide regular coaching, feedback, and career development support to direct reports; encourage ownership of individual career growth
• Participate in recruiting and employee development activities to build a balanced team with the right mix of skills
• Prepare and present delivery performance metrics, project insights, and status updates to GPS and senior leadership
• Drive continuous improvement initiatives that enhance client satisfaction, delivery quality, and team capability

Manager, Professional Services

Director

• Responsible for the end-to-end delivery of transformation initiatives that improve operational efficiency through technology enablement, product enhancements, and process implementation
• Execute defined transformation priorities by translating strategic objectives into actionable plans and delivering measurable outcomes
• Collaborate with Product, Technology, Operations, and Go-To-Market (GTM) teams to ensure that transformation initiatives improve internal efficiency and enable faster execution
• Coordinate across Product, Technology, Operations, and GTM teams to ensure timely delivery and monitor execution progress
• Support implementation of process improvements designed by the Process Excellence team
• Act as the day-to-day integrator across Product, Technology, Operations, GTM, and Process Excellence teams
• Apply transformation governance standards to assigned initiatives and track progress, risks, dependencies, and KPIs

Director of Transformation

• Lead Enterprise Reporting Transformation Program
• Define and drive the roadmap for a unified enterprise reporting framework
• Establish and own reporting on the status, progress, and impact of enterprise transformation initiatives
• Develop standardized views for leadership that provide clear visibility into milestones, risks, dependencies, and outcomes
• Partner closely with delivery, product, technology, and customer success teams
• Establish a structured approach to evaluating and prioritizing reporting initiatives
• Implement governance mechanisms to ensure standardization and accountability
• Lead end-to-end execution of transformation initiatives, from planning through delivery
• Manage interdependencies, risks, and trade-offs across multiple workstreams

Director, Enterprise Reporting Transformation

Auditor

• Perform audit of transactions processed by health plan administration associates for a specific customer.
• Be responsible for following the customer quality process and tools for audit and rebuttal process.
• Share QA results with individual associates, coordinate with operational Team Leads and managers to provide feedback to individuals, clearly identifying errors and opportunities of improvement.
• Collate, compile and reports both team and individual associates’ QA performance to management and individuals.
• Provide inputs to Training team and Team Leads for up-to-date written processing instruction/refresher training needs.
• Participate in semi-annual or annual auditor calibration activities.
• Maintain currency on CMS claims processing rules and guidelines for Medicare Advantage organizations and ACA Exchange and Off Exchange lines of business.

Quality Auditor

Risk

• Lead the strategy, roadmap, and execution for the product portfolio focused on retrospective risk adjustment solutions.
• Define multi-year plans aligned to customer outcomes, regulatory drivers, and market trends.
• Identify and prioritize use cases that leverage AI/ML and real-time data signals.
• Drive innovation leveraging interoperability standards (FHIR, HL7, APIs).
• Balance innovation with compliance and clinical integrity across all product decisions.
• Ensure products are clinically relevant, user-centric, and integrated with existing payer and provider workflows.
• Set and track KPIs for each product line.

Director, Risk Adjustment Products

Customer Success Manager

• Provide strategic leadership for large stakeholder relationships, tracking long and short-term goals in alignment with corporate strategy; while ensuring business revenue and EBIDTA growth, customer satisfaction and matrixed internal engagement.
• Partner with the client to solution customer problems and identify additional potential business opportunities.
• Enable quick wins for the organization by leveraging assets and teams within, with a focus on customer success.
• Show Quarterly progress on revenue and EBITDA aligned with corporate driven goals on P&L.
• Align with vendor management to ensure the ecosystem is performing as client expects.
• Prepare long-term and short-term goals and account objectives.
• Present reports on account progress, performance, SLAs and goals to senior leadership and stakeholders as well as percolate to matrixed team
• Apply extensive business and technological mastery to conceive and bring innovative ideas to fruition.
• Ensure constant learning on the business domain of current focus areas.
• Negotiate contracts on behalf of the company and establish cost parameters, budgets, campaigns, and ensure ROI on investments.
• Fully accountable and responsible for the business and for bringing in consistent cost controls throughout the business cycle and matrixed organizations.
• Motivate team members to exceed expected goals; ensure engagement and retention of key talent.
• Cast a leadership shadow and mentor others.

Client Success Executive

• Management and oversight of a quality team conducting quality assurance activities across multiple locations
• Oversight of key metrics, including quality, productivity, and compliance
• Responsible for the successful execution of the Quality Improvement Program

Manager, Clinical Quality

Product Manager

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Product Manager, Medicare Enrollment – Benefits

Product Manager, Medicare Provider Data Management

• Own and maintain the HealthRules Payer CMS integration catalog – defining the current state of each integration, its certification status, data exchange scope, technical specification version and planned roadmap investments.
• Develop and drive the multi-year CMS integration roadmap for HealthRules Payer, aligning integration investments with CMS regulatory milestones, federal rulemaking timelines and client demand signals.
• Evaluate new and evolving CMS system requirements – including FHIR API mandates under the Interoperability and Prior Authorization Final Rule (CMS-0057-F), CMS Data Services Hub enhancements and MACPro / MACFin modernization efforts – and translate obligations into HealthRules Payer integration requirements.
• Define the integration architecture principles for HealthRules Payer, establishing standards for API design, connector reuse, payload validation, error handling and integration observability in partnership with engineering and solution architecture.
• Monitor CMS technical bulletin releases, data services hub announcements and federal system decommission or migration notices, proactively assessing impact on HealthRules Payer integration continuity and driving necessary updates through the product backlog.
• Own product requirements for the HealthRules Payer API layer – defining RESTful API contracts, FHIR R4 resource profiles, authentication standards (OAuth 2.0, SMART on FHIR) and versioning policies that govern how internal and external systems connect to HealthRules Payer.
• Define requirements for a reusable connector framework within HealthRules Payer that enables health plan clients to configure, activate and monitor CMS system integrations without custom development – reducing implementation time and ongoing maintenance burden.
• Establish API design standards for HealthRules Payer outbound and inbound integrations, including payload schema definitions, error code taxonomy, retry logic, rate limiting and API lifecycle governance.
• Partner with engineering to define integration testing requirements – including unit, contract, regression and end-to-end testing protocols – ensuring each CMS integration maintains specification compliance across HealthRules Payer release cycles.
• Define product requirements for an integration monitoring and observability capability within HealthRules Payer, enabling health plan clients and HealthEdge operations teams to track integration health, transaction volumes, error rates and SLA performance in real time.
• Own product requirements for HealthRules Payer FHIR R4 API capabilities mandated under the CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F), including the Patient Access API, Provider Directory API, Payer-to-Payer API and Prior Authorization API.
• Translate Da Vinci Implementation Guide requirements – including PDex, PCDE, PAS, CRD and DTR – into HealthRules Payer FHIR API and integration configuration requirements, sequenced against CMS compliance effective dates.
• Define requirements for FHIR resource mapping between HealthRules Payer clinical and administrative data models and CMS-required FHIR profiles, ensuring data element completeness, terminology binding accuracy and conformance to US Core and CARIN IG standards.
• Manage HealthRules Payer FHIR certification requirements, coordinating with engineering and QA to maintain ONC certification alignment and CMS API compliance posture across product releases.
• Partner with implementation and client success teams to support health plan client FHIR API onboarding, third-party application registration workflows and payer-to-payer data exchange activation within HealthRules Payer.
• Define HealthRules Payer integration requirements for CMS EDI gateway connectivity, including EDISS/Medicare EDI transaction submission, acknowledgment processing and error resolution workflows for all HIPAA ASC X12 transaction sets.
• Own product requirements for batch data exchange integrations with CMS systems including MARx (Part D enrollment and TrOOP), CMS IDR/CCW (claims data access), PECOS (provider data feeds) and HPMS (plan data submissions).
• Define requirements for HealthRules Payer file format validation, transformation and routing capabilities to support CMS batch submission standards across EDI, fixed-width, CSV and XML payload formats.
• Ensure HealthRules Payer integration requirements address CMS data submission deadlines, file naming conventions, submission acknowledgment workflows and error resubmission processes for all batch-based CMS integrations.
• Own product requirements for CMS integration certification and testing processes applicable to HealthRules Payer – including CMS Data Services Hub certification, Medicare EDI testing, FHIR API conformance testing and applicable ONC certification criteria.
• Maintain a CMS integration compliance register for HealthRules Payer, tracking certification status, specification version currency, known gaps and remediation timelines for each integration in the catalog.
• Partner with regulatory and compliance teams to interpret CMS technical companion guides, system interface specifications and federal notice of proposed rulemaking (NPRM) technical appendices, translating obligations into HealthRules Payer integration backlog items.
• Serve as the primary integration subject matter expert for HealthRules Payer, partnering with engineering, solution architecture, implementation, client success and EDI operations teams to triage, prioritize and resolve integration-related product gaps.
• Define integration onboarding requirements for HealthRules Payer, ensuring health plan clients can activate, configure and test CMS integrations within a structured, documented implementation framework.
• Develop integration product documentation – including API reference guides, connector configuration specifications and CMS integration setup runbooks – in collaboration with technical writing and implementation teams.
• Collaborate with client success and implementation teams to capture integration feedback, escalate production issues and prioritize integration enhancements that reduce client operational friction and improve CMS data exchange reliability.

Product Manager, CMS Integrations

Full-stack Engineer

• Design, develop, and deploy scalable, enterprise-grade Java applications, leveraging SOA, EAI, and microservices architectures.
• Lead solution architecture discussions, design whiteboarding, and technical planning sessions.
• Mentor junior engineers and lead peer code reviews, enforcing best practices for maintainable and high-quality software.
• Develop unit tests (JUnit, TestNG), integration tests, and automated deployment pipelines for production-ready code.
• Work with CI/CD tools (Jenkins, Maven, Git) to streamline builds, deployments, and testing automation.
• Handle complex data integration, migration, and transformation tasks, ensuring data consistency and reliability.
• Collaborate with cross-functional teams to ensure successful UAT, production deployments, and client issue resolution.
• Apply AI/ML techniques, automation, and intelligent algorithms to enhance business processes, predictive analytics, and workflow optimization where applicable.
• Lead the implementation of integration frameworks, web services, and messaging solutions (JMS, SOAP/REST, ESB technologies).
• Support ongoing production and non-production system maintenance, including database tuning, performance optimization, and troubleshooting.

Senior Software Engineer

Systems Engineer

• Own the Salesforce platform for your GTM domain — configuration, automation, integrations and data.
• Partner directly with GTM teams to define our AI strategy and lead implementation.
• Embed yourself in how GTM teams actually work — surfacing friction before stakeholders have to tell you about it.
• Design solutions for longevity — anticipating what breaks three hops down the road and building for scale.
• Connect what you build to business outcomes and measure the impact.
• Contribute to the team's AI-first operating model using AI tools in your daily workflow.
• Support platform health: data integrity, security, integrations and responsiveness for end users.