Role Summary
Seeking a Healthcare Price Transparency SME with expertise in provider contracting, reimbursement methodologies, and MRF (Machine Readable File) generation. The role involves translating provider contracts, pricing data, and regulatory requirements into detailed technical requirements and business rules for engineering teams.
Key Responsibilities
- Lead requirements definition for Transparency in Coverage (TiC) and In-Network Rate MRFs.
- Analyze provider contracts, fee schedules, and reimbursement methodologies.
- Convert contract terms into negotiated-rate calculations and reporting rules.
- Develop and maintain Technical Requirements Documents (TRDs) covering data mappings, transformations, validations, calculations, and MRF output requirements.
- Identify data gaps, dependencies, exceptions, and reconciliation requirements.
- Partner with business, contracting, data, product, and engineering teams to support MRF implementation.
- Serve as the bridge between healthcare reimbursement concepts and technical development.
Required Experience
- 7+ years in US Healthcare Payer, Provider Contracting, Reimbursement, Healthcare Pricing, or Price Transparency.
- Experience with FACETS, HealthRules Payor (HRP), Amisys, or similar payer platforms.
- Strong understanding of reimbursement models such as Fee Schedule, Medicare %, DRG, APC, Per Diem, Case Rate, Capitation, Bundled Payments, and Fixed Rates.
- Proven ability to translate complex healthcare contracts into clear technical and business requirements.
Rate:
Not specified
Location:
Remote
IR35 Status:
Outside
Remote Status:
Remote
Industry:
Data & Analytics
Seniority Level:
Senior