Full Description

About Sonata Software

Sonata Software, with over $1.2 Billion Revenue, is a leading AI-first Modernization Engineering company, powered by our unique PlatformationTM framework. Our 6400+ AI Engineers are helping enterprises transform from systems to intelligent business platforms leveraging partner ecosystem to drive speed, efficiency and growth. Our bouquet of Modernization Engineering Services with AI -first approach cuts across Cloud, Data, AI, Dynamics, Test Automation, and Managed Services. Sonata’s AI-led modernization is enabled by a powerful suite of proprietary tools and assets. At the core is the Harmoni.AI Enterprise Platform, which includes Agent Bridge-a governance and observability framework; Agent Builder-a development toolkit for fungible agents integrated into enterprise systems; and the Agent Marketplace-an internal ecosystem for modular, reusable agents. Headquartered in Bengaluru, India, Sonata Software has a strong global presence, including key regions US, UK, India, Malaysia, Mexico, Australia, DACH (Germany/Switzerland) & Nordics (Finland). We are a trusted partner of Fortune 500 companies in Banking, Financial Services and Insurance; Healthcare and Lifesciences; Telecom, Media, and Technology; and Retail, Manufacturing and Distribution space.

Job Description: Healthcare Domain SME – Claim Validation & DMEPOS

Location: United States (Remote / Onshore)

Job Type: Full-Time

Working Hours: Must align with US Eastern Time (9 AM – 5 PM EST) to overlap with client SMEs.

About the Role We are seeking a highly specialized Healthcare Domain Subject Matter Expert (SME) with deep expertise in DMEPOS (Durable Medical Equipment, Prosthetics, Orthotics & Supplies) and Claim Validation. You will join a high-impact system modernization project for a leading specialty benefit management network (connecting 50+ health plans and 4,000+ DME providers). The project involves migrating a legacy, SQL-heavy claims processing system ("Que") to a modern, next-generation Azure-based microservices platform ("Prism"). As the Domain SME, you will bridge the gap between technical modernization teams and complex healthcare business rules, ensuring that over 500+ legacy claim validation rules are accurately understood, documented, and transitioned into the new configurable rule engine. Key Responsibilities

Domain Leadership: Serve as the primary authority on DMEPOS claims adjudication workflows, including CMS-1500 / 837P formats, prior authorizations, network credentialing, and cost containment strategies.

Legacy Rule Translation: Analyze and interpret existing claim validation logic across 14 core categories (e.g., Timely Filing, Medicaid Allowables, RR/NU Capped Rentals, Diagnosis Inclusion/HCPCS-to-Dx, Weight Rules).

Modifier & Coding Expertise: Ensure accurate handling of DME-specific billing nuances, such as KH/KI/KJ modifier sequencing, allowable units, and duplicate billing checks.

Modernization Support: Collaborate with software engineering and AI-assisted execution teams (utilizing AI Dev Kits) in a forward/reverse engineering pipeline to extract business rules from legacy T-SQL and map them to new Golang/Postgres targets.

Parity & Acceptance Testing: Define testing parameters to run 6 months of historical claims through both the legacy and modern systems. Validate outcomes to ensure 100% parity in rule enforcement.

SDLC Artifact Creation: Assist in creating comprehensive documentation required by the client, including Business/Product Requirements Documents (BRD/PRD), Data Flow Diagrams, test cases (TDD/BDD), and traceability matrices.

EDI & UI Rule Discovery: Look beyond legacy stored procedures to identify and document validation rules currently embedded in EDI inbound processes and UI layers. Required Qualifications

Domain Expertise: 7+ years of experience in US Healthcare claims processing, with a strict focus on DMEPOS (Orthotics, Prosthetics, and Durable Medical Equipment).

Claims Adjudication: Deep knowledge of professional claims routing, CMS-1500, 837P EDI transactions, HCPCS coding, and payer-specific coverage rules.

Business Analysis & Logic: Proven ability to deconstruct complex business rules and logic. Ability to translate operational requirements into technical specifications.

Healthcare Intermediary Knowledge: Understanding of the "three-sided network" in healthcare (Payers, Providers, and Members), particularly specialty benefit management and utilization management.

Data Privacy & Compliance: Extensive experience handling PHI/PII in HIPAA-compliant environments.

Clearance: Must be willing to undergo and pass a comprehensive background check prior to environment onboarding. Nice-to-Have (Preferred) Skills

SQL Fluency: Ability to read and navigate legacy T-SQL (Stored Procedures) to independently verify how existing validation rules are coded.

System Modernization Experience: Previous experience participating in legacy-to-cloud transformation projects.

Next-Gen Tech Awareness: Familiarity with modern rule engines, Golang, Azure, Kafka, or AI/GenAI-assisted software development lifecycles. Why this role? You will be the vital domain anchor on a high-visibility proof-of-concept (POC) that leverages cutting-edge AI and reverse-engineering platforms (Frontier Dev Kit) to modernize a massive healthcare infrastructure. Your deep knowledge of how an oxygen concentrator or knee brace claim gets validated, authorized, and paid will directly shape the logic of a platform handling thousands of claims daily.

Ensure the Domain SME can thrive in this AI-augmented environment, update the job description to include the following AI-specific competencies under the Responsibilities and Qualifications sections

Under "Key Responsibilities"

AI-Assisted Workflow Collaboration: Work directly within an AI-augmented pipeline, using tools like GitHub Copilot Chat and the Frontier Dev Kit to document, validate, and convert complex legacy logic into structured natural language instructions (Prompts) that guide AI code generation.

AI Output Validation: Act as the human-in-the-loop reviewer for AI-generated artifacts. Validate that AI-generated Golang business rules precisely match the healthcare requirements for DMEPOS modifier sequencing, HCPCS-to-Dx mapping, and RR/NU Capped Rentals.

Knowledge Base Curation: Help structure and refine internal Markdown documentation so that GitHub Copilot's repository context accurately understands Access Integra's specific business terminology and DMEPOS constraints.

Under "Nice-to-Have (Preferred) Skills"

AI Prompting & Copilot Familiarity: Experience using GitHub Copilot, Copilot Chat, or similar enterprise AI assistants to query codebases, generate testing parameters, or draft technical documentation.

Agentic QA Testing: Familiarity with generating structured synthetic test data or API payload requirements using AI to accelerate system parity testing.

Why join Sonata Software?

At Sonata, you´ll have an outstanding opportunity. The chance to use your skills and imagination to push the boundaries of what´s possible. To build never seen before solutions to some of the world’s toughest problems. You´ll be challenged, but you will not be alone. You´ll be joining a team of diverse innovators, all driven to go beyond the status quo to craft what comes next. Sonata Software is an Equal Opportunity Employer encouraging diversity in the workplace. All qualified applicants will receive consideration for employment without regard to race, national origin, gender identity, age, religion, disability, sexual orientation, veteran status, marital status, or any other characteristics protected by law.