Project overview
About the Role We are seeking a highly skilled and experienced Claims Adjudication Workflow Subject Matter Expert (SME) with hands-on knowledge of HealthRules Payer, EZ-CAP, and Javelina systems. This role is critical in supporting the optimization, integration, and troubleshooting of claims processing workflows across multiple platforms. The SME will serve as a bridge between business operations, IT, and vendor teams to ensure efficient, accurate, and compliant claims adjudication. Key Responsibilities Act as the lead SME for claims adjudication workflows across HealthRules Payer, EZ-CAP, and Javelina platforms. Analyze and document current claims processes and recommend improvements for efficiency, accuracy, and compliance. Collaborate with cross-functional teams including Claims Operations, IT, Configuration, QA, and Compliance to support system upgrades, configuration changes, and new implementations. Support the integration and migration of adjudication functions between platforms, ensuring minimal disruption to operations. Participate in user acceptance testing (UAT), system configuration validation, and root cause analysis for adjudication issues. Develop and deliver training and documentation for business users and technical teams regarding system functionality and best practices. Serve as a liaison with system vendors to escalate and resolve platform-related issues or enhancement requests. Monitor system performance and claims processing accuracy, identifying and resolving anomalies. Ensure compliance with applicable regulatory and contractual requirements in claims processing. Qualifications/Requirements 5+ years of hands-on experience in claims adjudication, including in-depth workflow understanding. Demonstrated expertise in all of the following systems: HealthRules Payer, EZ-CAP, and Javelina (experience in all three preferred). Strong understanding of healthcare insurance industry operations, including benefits configuration, provider contracts, eligibility, and regulatory compliance (e.g., CMS, HIPAA). Proven track record of systems implementation, migration, or integration projects within payer environments. Excellent analytical, problem-solving, and communication skills. Experience writing detailed business and technical documentation.