Claims Modernization for Regional Health Insurer

A regional health plan was experiencing long claim cycles and manual handoffs due to legacy adjudication systems. As consulting CTO, I led a transformation to modernize the claims infrastructure with secure APIs, real-time eligibility checks, and integration with major clearinghouses.

Project Snapshot:
The insurer relied on batch file workflows and internal staff to resolve mismatched claims. Eligibility checks, claim edits, and member lookup were all manual. My role was to build a modern, scalable, and interoperable claims platform.

Key Challenges:

48–72 hour claims lag due to manual adjudication
No API connectivity to clearinghouses or eligibility providers
Non-compliance risk due to PHI handling in unsecured systems
Provider complaints on denial turnaround time

What I Did / Led:

Designed and deployed FHIR-compatible claims and eligibility API layer
Integrated Availity and Change Healthcare as clearinghouse partners
Implemented audit-ready PHI encryption and access logging
Built provider dashboard with claim status, denials, and EOB visualization
Aligned internal dev teams with external compliance officers

Impact:

Cut claim turnaround time by 60%
Improved first-pass adjudication by 43%
Reduced provider escalations by 80%
Passed annual HIPAA audit with zero corrective actions

Tech Stack:
McKesson, FHIR APIs, Azure App Gateway, .NET Core, SQL Server, OAuth2, Availity, Change Healthcare