TL;DR
Large payers face constant ACA, CMS, and HIPAA change plus complex client-specific demands. I owned regulation-driven product updates and a first-of-its-kind claims build for major Blue Cross Blue Shield clients — keeping them audit-ready and penalty-free.
The Problem
Highmark's enterprise healthcare platform serves payers end to end — enrollment, billing, provider search, claims adjudication, and member explanations of benefits. Clients across multiple states had to stay compliant with continually shifting ACA, CMS, and HIPAA rules, and some had non-traditional requirements the platform had never supported.
The Approach
I worked as the bridge between client business needs and the platform's engineering reality. For a large client onboarding (e.g., a major employer through a BCBS plan), I took a non-traditional claims-adjudication request that had never been implemented in the industry, mapped the client's processes, and translated them into a delivery proposal scrutinized line by line across finance, legal, product, and leadership before executive approval.
The Solution
For compliance-driven work, I owned delivery of regulation updates for multiple clients across states, coordinating legal, ops, and engineering to land changes before deadlines. I also ran roadmap-collaboration sessions with key clients — co-prioritizing features and translating business needs into technical scope — which improved transparency and trust. I separately led automated Explanation-of-Benefits work, using unsupervised learning on member complaints to fix recurring problem patterns (cost-sharing confusion, duplicate line items, unclear denial codes) rather than one-offs.
The Impact
The compliance updates helped clients avoid roughly $2M in regulatory fines; the EOB work cut manual errors by ~40% and reduced EOB-related calls by double digits, with a reusable framework for documents like prior-auth notices. Client CSAT on the accounts I led rose from 7.0 to 9.2, strengthening retention.