Senior Health Business Architect - Health Insurance Payer Domain

BC sector health-Senior-Health Business Architect

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Job Description: Health Business Architect – Payer Domain

Role Overview

We are seeking a seasoned Business Architect with deep experience in the health insurance (payer) domain and hands-on expertise with Health technologies. The candidate will serve as a strategic consulting partner to business and IT, own the end-to-end business architecture, and lead the design and delivery of health business-enabled capabilities across claims, benefits, provider, and member operations.

 

Key Responsibilities

• Leads end to end business architecture development across core healthcare payer functions such as claims, enrolment, provider network, care management, UM/CM, and billing.
• Aligns business strategy, technology solutions, and operating models to enable enterprise transformation.
• Develops capability models, value streams, future state process designs, and target operating models to guide modernization initiatives.
• Conducts current state assessments, identifies operational and system gaps, and recommends improvements to drive efficiency, compliance, and member/provider experience.
• Partners closely with product, IT, clinical and operations teams to design and support digital transformation and platform implementations.
• Acts as a bridge between business stakeholders and technical teams, translating requirements into functional designs and ensuring solution alignment.
• Builds strategic roadmaps, business cases, and value realization plans to articulate benefits and investment priorities.
• Ensures alignment with regulatory requirements such as CMS, HIPAA, NCQA, HEDIS, and payer compliance standards.
• Supports change management, communication, and adoption planning to ensure smooth rollout of new processes and systems.
• Facilitates executive-level presentations, strategic discussions, and decision support for transformation initiatives.

 

Required Qualifications

• 8–12+ years of experience in the healthcare payer domain, with a strong consulting background leading large scale business and technology transformation initiatives.
• Deep understanding of payer core administration platforms (e.g., HealthEdge, Facets, QNXT, Health Rules, Javelina, or similar technologies), with experience in solution design, business architecture, configuration oversight, or product leadership.
• Strong functional expertise across key payer operations, including claims processing, benefit/product modeling, provider data management, pricing & payment integrity, accumulators, enrollment & membership, and customer service workflows.
• Demonstrated ability to lead executive and SME workshops, facilitate requirement discovery, and produce high quality deliverables such as process maps, capability models, business architecture blueprints, and transformation roadmaps.
• Comprehensive understanding of regulatory and compliance requirements, including HIPAA, CMS mandates, Medicare/Medicaid policies, and state specific payer regulations.
• Excellent communication, stakeholder management, and documentation skills, with the ability to translate complex business needs into technology aligned solutions and effectively bridge business and IT teams.
• Proven experience working in agile environments, including participation in PI planning, backlog refinement, user story creation, acceptance criteria definition, and leadership of UAT cycles.

 

Preferred Qualifications

• Experience working across multiple health plan types—including national and regional commercial plans, Medicare Advantage, Medicaid, and employer group plans—with a proven track record of supporting successful system deployments and go lives.
• Exposure to leading healthcare payer and care management platforms such as HealthEdge Source (payment integrity), GuidingCare (care management), Wellframe (member engagement), and industry standard provider data management solutions.
• Knowledge of integrations involving CRM platforms (e.g., Salesforce), enterprise data ecosystems (EDW, Lakehouse), clearinghouses, PBMs, utilization management systems, and other ecosystem interfaces commonly used in payer environments.
• Professional certifications such as AHIP, or product specific training/certifications on market leading payer platforms (e.g., HealthEdge, Facets, QNXT, or similar), demonstrating strong domain and solution expertise.
• savings, provider data accuracy, and member NPS; drive continuous improvement.

 

Education

• Bachelor’s or Master’s degree in Business, Healthcare Administration, Information Systems, or related field.

 

Location & Work Model

• Preferred location: Open to onshore/offshore hybrid model; ability to travel for key workshops and go-live support as needed.

 

Equal Opportunity Employer

• We are an equal opportunity employer and value diversity. All employment is decided based on qualifications, merit, and business need.

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Experience Level

Senior Level