Talme Technologies (Engineering services)
Website:
talme.in
Job details:
Location – Bangalore/Noida
Exp – 5+years
Key Responsibilitie
Prior Authorization & ABRE Configuration
- Configure and promote ABRE rules engine logic to support Prior Authorization (PA) processes.
- Develop and maintain auto-authorization rules for codified authorization types.
- Configure complex authorization logic involving eligibility, pairing, and business rules.
- Reconfigure PAD exclusion logic and resolve dependencies between CCA and Facets.
- Support optimization and automation of UM workflows.
Correspondence & RightFax Integration
- Configure TriZetto Communication System (TCS) correspondence automation.
- Implement automated letter generation workflows to reduce manual intervention.
- Configure and support RightFax two-way integrations.
- Collaborate with business and technical teams to implement fax automation solutions.
Clinical Workflow & Compliance Configuration
- Configure clinical triage safeguards and workflow controls.
- Implement automated case closure integrity rules.
- Configure user-defined fields (UDFs), including audit trail visibility requirements.
- Support workflow and visibility enhancements for Appeals & Grievances (A&G) processes.
- Configure Clinical Reviewer Profiles and Group Restrictions.
- Ensure compliance with regulatory and operational requirements.
Benefit, Pharmacy & Drug Review Configuration
- Configure benefit plans and authorization routing logic within CCA.
- Support pharmacy and provider-administered drug review workflows.
- Configure State Medicaid pairing logic and related compliance requirements.
- Maintain alignment between benefit mapping, ABRE rules, and PA lists.
Case Management & Workflow Automation
- Configure automated case creation and closure rules.
- Analyze and migrate manual tracking processes maintained in spreadsheets and email into CCA workflows.
- Improve operational efficiency through workflow automation.
- Support system enhancements and modernization initiatives.
Documentation & Upgrade Readiness
- Develop and maintain configuration documentation.
- Support future CCA and TCS upgrade readiness planning.
- Participate in solution design, testing, deployment, and knowledge transfer activities.
- Provide recommendations for system optimization and best practices.
Required Qualifications
- 2+ years of healthcare payer experience.
- 5+ years of hands-on configuration experience with TriZetto Clinical CareAdvance (CCA).
- Strong experience with:
- ABRE Rules Engine
- Prior Authorization (PA) workflows
- Utilization Management (UM)
- Appeals & Grievances (A&G)
- TriZetto Communication System (TCS)
- RightFax Integration
- Benefit and Pharmacy Configuration
- Knowledge of Medicaid and healthcare regulatory requirements.
- Experience integrating CCA with Facets or other core administration platforms.
- Strong analytical, troubleshooting, and stakeholder management skills.
Preferred Qualifications
- Experience with Facets Configuration and Administration.
- Experience supporting healthcare modernization programs.
- Knowledge of workflow automation and case management solutions.
- Experience with healthcare interoperability and integration projects.
- Bachelor's degree in Information Systems, Healthcare Administration, Computer Science, or a related field.
Deliverables
- Auto-authorization solutions configured and operational.
- ABRE rules and PA workflow enhancements implemented.
- TCS correspondence automation and RightFax integrations configured.
- Clinical workflow safeguards and compliance controls implemented.
- Pharmacy, Medicaid, and provider-administered drug workflows configured.
- Automated case management processes established.
- Comprehensive configuration and upgrade readiness documentation delivered.
Domain: Healthcare Payer | Utilization Management | Prior Authorization | Clinical CareAdvance (CCA) | Facets | Medicaid | Appeals & Grievances.
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