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Healthcare Claims Integration Consultant (Dual Claims Aetna / Medicare / Medicaid)
Overview
Engagement Type: Remote High-priority, immediate start
Start Timeline: ASAP (Target onboarding: Early-July)
We are seeking a highly experienced Healthcare Claims Integration Consultant to support a strategic healthcare initiative focused on dual claims processing, payer integration, and cost optimization in collaboration with Aetna and related healthcare programs.
This role is critical to supporting a large-scale healthcare transformation involving Medicare and Medicaid coordination, dual claims strategy, and payer operational alignment.
The consultant will work closely with executive leadership (CIO/President level stakeholders) to design and implement a scalable approach for claims integration and cost efficiency.
Key Responsibilities
- Lead design and advisory for dual claims strategy and integration frameworks
- Support healthcare payer alignment involving Aetna, Medicare, and Medicaid
- Analyze and optimize claims workflows, coordination of benefits (COB), and adjudication processes
- Define and recommend operating models for cost reduction and claims efficiency
- Collaborate with executive stakeholders to translate business needs into technical and operational solutions
- Evaluate current-state claims processes and identify gaps, risks, and integration opportunities
- Provide advisory support for payer integration during acquisition or organizational transition
- Guide implementation strategy for claims data exchange and interoperability
- Support development of roadmaps, governance models, and execution plans
Required Experience
- 10+ years in healthcare payer/claims domain
- Strong expertise in claims processing, adjudication, and payer operations
- Hands-on experience with dual claims / coordination of benefits (COB)
- Exposure to Medicare and Medicaid programs and regulatory frameworks
- Experience working with or alongside Aetna or similar large national payers
- Strong understanding of healthcare cost structures and reimbursement models
- Experience in payer integration, healthcare transformation, or acquisition support
- Ability to engage with CIO, VP, and executive-level stakeholders
Preferred Experience
- Healthcare consulting background (Big 4 or boutique healthcare advisory)
- Experience with claims platforms, payer systems, or healthcare data integration
- Familiarity with EDI transactions (837/835), HIPAA compliance
- Experience in large-scale payer modernization programs
Soft Skills
- Strong executive communication and stakeholder management
- Strategic thinking with ability to operate in ambiguous environments
- Ability to bridge business, clinical, and technical teams
- Problem-solving mindset with focus on measurable cost impact
Ideal Candidate Profile
A senior healthcare domain expert who has:
- Designed or led claims integration or dual claims programs
- Worked with large payer ecosystems (Aetna strongly preferred)
- Delivered cost optimization and operational transformation in healthcare claims environments