Senior Product Researcher – Health Plan Systems

Senior Product Researcher – Health Plan SystemsLocation: Tampa, FL Compensation: $100,000Position OverviewWe are seeking an experienced Senior Product Researcher – Health Plan Systems to serve as a subject matter expert (SME) in healthcare payer operations and technology.This position requires strong functional expertise in Member Enrollment, Claims Adjudication, and Payment Management, with the ability to research emerging industry trends, analyze regulatory changes, and translate complex business requirements into actionable product recommendations.The ideal candidate has hands-on experience working with health plan administration systems and understands how healthcare payer processes operate across Medicaid, Medicare Advantage, and commercial insurance.This individual will collaborate closely with Product Management, Business Analysts, Engineering, and senior leadership to evaluate product opportunities, establish requirements, and support the development of innovative healthcare technology solutions.Key ResponsibilitiesProduct Research & Business AnalysisResearch emerging technologies, market trends, and regulatory developments affecting healthcare payer systems.Evaluate new product concepts and features for business feasibility, regulatory compliance, and market demand.Gather and analyze requirements from clients, business stakeholders, and internal teams.Translate complex business needs into clear, structured, and prioritized product requirements.Conduct competitive research on health plan administration platforms, claims processing systems, and enrollment technologies.Identify opportunities to improve operational efficiency, product functionality, and customer experience.Present research findings and recommendations to senior leadership.Healthcare Payer Subject Matter ExpertiseServe as an internal subject matter expert across member enrollment, claims adjudication, and payment management.Analyze end-to-end health plan workflows to identify process gaps and opportunities for improvement.Provide guidance on payer business rules, regulatory requirements, and operational processes.Support product teams in understanding the functional requirements of healthcare administration systems.Stay informed on CMS regulations, HIPAA, ACA requirements, and state Medicaid mandates.Product Development & CollaborationCollaborate with Product Managers, Business Analysts, and Engineering teams to translate research into actionable product requirements.Support product prioritization and backlog sequencing based on business needs, dependencies, and regulatory requirements.Evaluate proposed features to ensure alignment with healthcare payer workflows.Maintain organized documentation of business requirements, industry research, and regulatory updates.Mentor junior researchers and analysts on payer operations and research methodologies.Required Domain ExpertiseMember EnrollmentMember eligibility verification and enrollment processing.Enrollment and disenrollment workflows.Group and individual health plan enrollment.Medicare, Medicaid, and commercial insurance enrollment processes.COBRA and open enrollment requirements.EDI 834 transactions and enrollment data exchange.Claims AdjudicationEnd-to-end healthcare claims processing and adjudication.Claims intake, validation, pricing, edits, denials, and adjustments.EDI 837 claims transactions and EDI 835 remittance transactions.Benefit plan configuration and claims processing rules.ICD-10, CPT, and HCPCS coding standards.Claims management systems and adjudication workflows.Payment ManagementProvider reimbursement and payment processing.Fee-for-service, capitation, and value-based reimbursement models.Payment integrity and overpayment recovery.Provider payment reconciliation.Coordination of Benefits (COB).Subrogation and payment adjustment processes.Required Qualifications5–8+ years of experience in healthcare payer operations, product research, business analysis, or related subject matter expert positions.Demonstrated hands-on expertise in at least two of the following three areas: Member Enrollment, Claims Adjudication, or Payment Management.Strong understanding of healthcare payer systems and health plan administration platforms.Experience translating complex business and client requirements into structured product documentation.Knowledge of healthcare regulations, including HIPAA, ACA, CMS guidelines, and Medicaid requirements.Strong analytical, research, and problem-solving abilities.Experience working collaboratively with product, technical, and business stakeholders.Excellent communication, presentation, and documentation skills.Bachelor's degree in Healthcare Administration, Business, Information Systems, or a related field.Preferred QualificationsExperience supporting Medicare Advantage or Medicaid managed care programs.Experience working directly with health plan clients or payer configuration teams.Familiarity with Agile/Scrum methodologies and product backlog management.Knowledge of product prioritization frameworks such as RICE or Jobs-to-be-Done.Understanding of healthcare interoperability standards, including FHIR and X12 EDI.Master's degree in a related discipline. 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