Highly desirable to have knowledge in overall US Healthcare domain Evaluating business processes, anticipating requirements, uncovering areas for improvement, and developing and implementing solutions. Leading ongoing reviews of business processes and developing optimization strategies. Performing cost-benefit-analysis to see which option is better amongst the available choices Effectively communicating your insights and plans to cross-functional team members and management.

1 .Utilization Management Workflow Optimization:Lead the REquirement elicitation for end-to-end payer utilization management (UM) workflows for automated, rapid-track, and nurse/medical director manual reviews.

2.EDI & Interoperability Compliance:Drive compliance for electronic prior authorization using EDI 278 (ePA) transactions, HL7 FHIR standards, and CMS-mandated Interoperability APIs.





3.Medical Policy & Rules Engine Translation:Translate complex payer medical necessity guidelines, coverage policies, and CPT/ICD-10 clinical rules into configurable logic within decision engines.

4.EHR-to-Payer System Integration:Partner with technical teams to establish seamless integrations between provider EHRs and internal payer authorization/claims engines via FHIR or other protocols.

5.Denial Reduction & TAT Analytics:Analyze authorization turnaround times (TAT), auto-approval rates, and intake error trends to identify bottleneck root causes and reduce administrative friction.

6. Around 10-12 years of experience in Payer industry. Good communication and solutioning skill

📌 Business Analyst (Bengaluru)
🏢 TRIGENT SOFTWARE PRIVATE
📍 Bengaluru