Provider Application SME

Job Description

Job Title: Provider Application SME (Technical)

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Key Responsibilities: Onshore US Remote

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Experience: 12 to 15 years

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Summary

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We need a Provider Application Expert with hands-on build experience in Provider Data Management (PDM) and Provider Network/ Contracts applications. This role owns the technical design of provider data workflows, drives rules-based automation, and architects integrations across Claims, Provider Directory, Portal, and other downstream systems.

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Key Responsibilities

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• Design, configure, and support Provider Data Management and Provider Contracts modules on the core admin platform, including provider onboarding, credentialing data, network/panel assignment, and contract term modeling
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• Automate provider data business processes using rules engines (e.g., Drools, Kogito) and workflow/BPM configuration
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• Architect and build upstream/downstream integrations with Claims adjudication, Provider/Member Portals, and Provider Directory systems using REST/SOAP APIs, message queues, or ETL pipelines
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• Own data mapping and transformation logic between provider source-of-truth systems and downstream consumers (claims pricing, network adequacy, directory publishing)
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• Implement and troubleshoot data integrations relevant to provider data (e.g., Provider data hierarchy, enrollment linkage where applicable)
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• Build and maintain provider data quality rules: deduplication logic, match/merge algorithms, validation rulesets, and exception-handling workflows
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• Support CI/CD-based config promotion across environments (dev/test/prod) for provider application changes
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• Partner with delivery leads to translate business/functional requirements into technical specs, data models, and configuration artifacts
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Required Technical Skills

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• Hands-on development/configuration experience in Provider Data Management and Provider Contracts applications for Health plans with core admin platform integrations.
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• Strong understanding of provider data models: NPI/TIN structures, provider-to-contract-to-network relationships, roster/panel data, credentialing attributes
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• Integration development experience — REST/SOAP APIs, batch/file-based interfaces, or middleware (MuleSoft, Boomi, etc.) connecting to Claims, Portal, and Directory systems
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• SQL proficiency for data validation, troubleshooting, and reporting against provider data stores
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Advantageous Skills

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• EDI transaction experience, and related provider/network transaction sets
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• Provider data quality tooling experience: match/merge, MDM platforms, or data governance frameworks
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• Contracts automation experience — rules-based contract term application, fee schedule automation, or rate configuration engines
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• Experience with rules engines such as Drools/Kogito for automating provider workflow logic
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• Familiarity with CI/CD pipelines for platform config promotion
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