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