Location: USA Remote
Employment Type: W2 Contract
Contract Rate: $60/hr on W2
Salary: $150K gross salary, including 15% QPLC
Experience: 10+ Years
Domain: Healthcare Payer | Behavioral Health (BH)
Only visa-independent candidates who are eligible to work on W2 will be considered. USC candidates preferred.
Role OverviewWe are seeking a seasoned Behavioral Health SME with strong Business Analysis and Healthcare Payer systems expertise to support payer transformation initiatives.
The ideal candidate will have deep knowledge of Behavioral Health operations, end-to-end payer processes, healthcare regulations, and payer technology platforms, with the ability to effectively bridge business and technology teams.
Key Requirements10+ years of Healthcare Payer experience, including 5+ years of Behavioral Health experience covering Mental Health and Substance Use Disorders.
Strong understanding of the end-to-end payer lifecycle:
Eligibility & Enrollment
Benefits Configuration
Claims Processing & Adjudication
Prior Authorization
Care & Case Management
Provider Management
Appeals & Grievances
Payment Integrity
Deep knowledge of Behavioral Health regulations and standards, including:
MHPAEA (Mental Health Parity and Addiction Equity Act)
Medicare & Medicaid Behavioral Health programs
HIPAA
CMS and state-specific regulatory requirements
NCQA / URAC standards
Strong Business Analysis skills, including:
Requirements gathering
BRD / FRD development
User Stories
Process mapping
Gap analysis
UAT / SIT support
Stakeholder management
Experience with payer platforms such as Facets, QNXT, HealthRules, GuidingCare, TruCare , or similar platforms.
Knowledge of healthcare transactions and interoperability standards:
837
835
834
270/271
HL7 / FHIR
Strong SQL, data analysis, and healthcare system integration experience.
Experience with Commercial, Medicare, and Medicaid lines of business.
Exposure to Behavioral Health Care Management, Utilization Management, and Value-Based Care programs.
Experience with payer modernization, data, AI, or digital transformation initiatives.
The ideal candidate will be a Behavioral Health Payer SME who combines deep business process knowledge, regulatory expertise, system knowledge, and Business Analysis skills, with proven experience across:
Behavioral Health + Claims + Eligibility + Benefits + Care Management + Provider Operations + Regulatory Compliance + Payer Technology Platforms
The candidate should be capable of driving both strategic business discussions and detailed system-level solution design discussions with equal effectiveness.
Submission RequirementPlease submit suitable profiles matching the required skill set at your agreed rate card with Wipro .
Important: Only visa-independent candidates eligible to work on W2 will be considered. USC candidates preferred.
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