Provider Application SME

Job Title: Provider Application SME (Technical)
Key Responsibilities: Onshore US Remote
Experience: 12 to 15 years
Summary
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.
Key Responsibilities
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
Automate provider data business processes using rules engines (e.g., Drools, Kogito) and workflow/BPM configuration
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
Own data mapping and transformation logic between provider source-of-truth systems and downstream consumers (claims pricing, network adequacy, directory publishing)
Implement and troubleshoot data integrations relevant to provider data (e.g., Provider data hierarchy, enrollment linkage where applicable)
Build and maintain provider data quality rules: deduplication logic, match/merge algorithms, validation rulesets, and exception-handling workflows
Support CI/CD-based config promotion across environments (dev/test/prod) for provider application changes
Partner with delivery leads to translate business/functional requirements into technical specs, data models, and configuration artifacts
Required Technical Skills
Hands-on development/configuration experience in Provider Data Management and Provider Contracts applications for Health plans with core admin platform integrations.
Strong understanding of provider data models: NPI/TIN structures, provider-to-contract-to-network relationships, roster/panel data, credentialing attributes
Integration development experience — REST/SOAP APIs, batch/file-based interfaces, or middleware (MuleSoft, Boomi, etc.) connecting to Claims, Portal, and Directory systems
SQL proficiency for data validation, troubleshooting, and reporting against provider data stores
Advantageous Skills
EDI transaction experience, and related provider/network transaction sets
Provider data quality tooling experience: match/merge, MDM platforms, or data governance frameworks
Contracts automation experience — rules-based contract term application, fee schedule automation, or rate configuration engines
Experience with rules engines such as Drools/Kogito for automating provider workflow logic
Familiarity with CI/CD pipelines for platform config promotion

Work arrangement
No