Title : HealthRules Payer Technical Configuration & Automation Engineer / Specialist
Location : Philadelphia , PA onsite
Job Summary :
We are seeking a HealthRules Payer Technical Configuration & Automation Engineer/Specialist to own hands-on configuration, troubleshooting, and automation across the HealthRules Payer platform. This role bridges deep technical configuration expertise with payer domain knowledge — spanning claims adjudication, Coordination of Benefits (COB), Home & Host/Blue Card processing, and ITS ecosystem workflows — while building automation frameworks that improve testing, validation, reconciliation, and operational efficiency. The ideal candidate combines the precision of a configuration analyst with the mindset of an automation engineer.
Key Responsibilities
- Design, build, and maintain HealthRules Payer configuration across products, benefits, contracts, and business rules.
- Develop and modify custom logic using HealthRules Language (HRL) to support complex business and adjudication requirements.
- Configure and troubleshoot COB rules, edits, and primacy logic to ensure accurate primary/secondary claim processing.
- Support Home & Host and Blue Card/ITS configuration, ensuring correct inter-plan claim, eligibility, pricing, and financial transaction handling.
- Trace and resolve claims configuration and data issues, identifying root causes across benefits, elccigibility, provider, and COB logic.
- Build native Python automation tools for configuration validation, regression testing, reconciliation, and operational reporting.
- Design and execute automated test scenarios for large-scale claims testing and configuration regression coverage.
- Query and analyze claims, member, eligibility, configuration, and financial data using SQL to validate outcomes and support decision-making.
- Partner with business, QA, and integration teams to identify process gaps and recommend modernization or automation opportunities.
- Document configuration standards, automation frameworks, and test results to support audits, governance, and knowledge transfer.
Technical Skills
- HealthRules Payer Configuration – Hands-on configuration experience across products, benefits, and business rules (not limited to functional/theoretical knowledge).
- HealthRules Language (HRL) – Ability to independently develop and modify rules and configuration logic using HRL.
- COB Configuration – Hands-on experience configuring COB rules, edits, primacy-related logic, and associated claims processing.
- Home & Host Configuration – Practical configuration experience with HealthRules Home/Host capabilities and cross-plan setup.
- Claims Configuration & Troubleshooting – Ability to trace claim outcomes end-to-end and pinpoint configuration or data root causes.
- Python Automation – Strong, demonstrable proficiency in native Python for automating configuration validation, testing, reconciliation, and operational workflows.
- Test Automation / Regression Testing – Experience automating HealthRules configuration testing and large-scale claims scenario validation.
- API / Integration Knowledge – Working understanding of APIs, HealthRules integration points, external system connectivity, ITS/Blue ecosystem data exchange.
- SQL & Data Analysis – Ability to write and optimize queries across claims, member, eligibility, configuration, and financial data for analysis and validation.
- Automation Engineering Mindset – Ability to design reusable tools/frameworks for configuration comparison, test-data generation, defect identification, reconciliation, and reporting. UiPath experience is a plus, not a requirement.
Payer Domain Skills
- HealthRules Payer Functional Knowledge – Strong understanding of how HealthRules supports core payer operations and business processes.
- COB End-to-End Knowledge – Working knowledge of COB discovery, other coverage identification, primacy determination, primary/secondary processing, and downstream financial impact.
- COB Edits & Adjudication – Understanding of how COB edits drive claim pends, denials, reprocessing, and payment outcomes.
- Home & Host / Blue Card / ITS Ecosystem – Strong understanding of Home Plan vs. Host Plan operations and out-of-area member processing, including ITS Home/Host, BlueSquare, and BlueCard claim processing.
- Blue Card / ITS Processes – Understanding of inter-plan claim routing, eligibility verification, pricing, adjustments, and financial settlement transactions.
- Claims Adjudication – Comprehensive understanding of the claim lifecycle and how benefits, eligibility, provider contracts, and COB rules influence payment.
- Self-Funded Payer Business – Understanding of financial responsibility structures and operational nuances specific to self-funded groups.
- Fully Funded / Fixed-Funded Products – Understanding of product-specific business rules and the operational differences across funding arrangements.
- Billing & Financial Reconciliation – Understanding of how COB and claims outcomes flow into billing, recovery, reconciliation, and financial reporting.
- Payer Process Analysis – Ability to identify gaps between current-state business processes, HealthRules configuration, surrounding systems, and manual operations, and translate findings into modernization opportunities.
Qualifications
- Bachelor’s degree in computer science, Information Systems, Healthcare or related field (or equivalent practical experience).
- 3+ years of hands-on Health Rules Payer configuration experience.
- Demonstrated experience with HRL development, COB configuration, and Home & Host/Blue Card processing.
- Proven Python scripting/automation experience in a production or enterprise environment.
- Strong SQL skills with experience querying complex healthcare data models.
- Experience in a health plan, payer, or healthcare IT environment strongly preferred.
- Familiarity with ITS/BlueCard/BlueSquare inter-plan processes strongly preferred.
Soft Skills
- Strong analytical and root-cause problem-solving abilities.
- Ability to translate business/functional requirements into technical configuration and automation solutions.
- Clear communicator, able to work across business, QA, and technical teams.
- Detail-oriented with a strong sense of ownership over configuration accuracy and data integrity.
Pay: $88,148.55 - $106,157.39 per year
Work Location: In person