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, quick-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

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