Healthcare Claims Integration Consultant (Dual Claims Aetna / Medicare / Medicaid)

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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
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