Claims adjuster Jobs in Pembroke Pines, FL

NationsBenefits is recognized as one of the fastest-growing companies in America and a Healthcare Fintech provider of supplemental benefits, flex cards, and member engagement solutions. We partner with managed care organizations to provide innovative healthcare solutions that drive growth, improve outcomes, reduce costs, and bring value to their members.Through our comprehensive suite of innovative supplemental benefits, fintech payment platforms, and member engagement solutions, we help health plans deliver high-quality benefits to their members that address the social determinants of health and improve member health outcomes and satisfaction.Our compliance-focused infrastructure, proprietary technology systems, and premier service delivery model allow our health plan partners to deliver high-quality, value-based care to millions of members.We offer a fulfilling work environment that attracts top talent and encourages all associates to contribute to delivering premier service to internal and external customers alike. Our goal is to transform the healthcare industry for the better! We provide career advancement opportunities from within the organization across multiple locations in the US, South America, and India.

Location: Plantation, FL (On-site)

Senior Data Engineer

About the Role

We are seeking an experienced Senior Data Engineer – EDI Claims Processing to join our growing Data Engineering team. This role is responsible for designing, developing, and maintaining enterprise-scale healthcare data integration solutions focused on HIPAA X12 EDI transactions, Medicaid encounters, and CMS compliance.

The ideal candidate has extensive experience building high-volume data pipelines using Databricks and SQL Server, a deep understanding of HIPAA X12 transaction standards, and hands-on experience supporting healthcare claims processing, clearinghouse integrations, and regulatory compliance.

This is an excellent opportunity for a healthcare data engineering professional who enjoys solving complex integration challenges while delivering reliable, scalable, and compliant data solutions.

Key Responsibilities

EDI Data Pipeline Engineering

• Design, develop, and optimize enterprise-grade ingestion, parsing, validation, transformation, and delivery pipelines for HIPAA X12 transactions, including:
  • 837 (Professional, Institutional, Dental Claims)
  • 277CA (Claims Acknowledgment)
  • 999 (Implementation Acknowledgment)
  • 834 (Member Eligibility)
  • 835 (Remittance Advice)
• Build scalable, high-performance ETL/ELT workflows using Databricks, PySpark, Delta Lake, and SQL Server.

Claims & Encounter Processing

• Manage Medicaid encounter submissions, reconciliation, and error remediation with state Medicaid agencies.
• Support CMS encounter processing by implementing regulatory updates, schema changes, and compliance requirements.
• Collaborate with internal teams to ensure accurate and timely claims submissions.

Data Integration & Validation

• Develop automated validation frameworks to ensure HIPAA compliance, SNIP validation, and business rule enforcement.
• Maintain secure and reliable integrations with healthcare clearinghouses and trading partners.
• Analyze and troubleshoot complex EDI processing issues across multiple systems.

Operational Excellence

• Build monitoring, alerting, logging, and SLA reporting for production EDI workflows.
• Continuously improve pipeline performance, scalability, and reliability.
• Maintain technical documentation, mapping specifications, companion guide implementations, and data dictionaries.

Cross-Functional Collaboration

• Partner with Claims Operations, Compliance, Product, IT Security, and external healthcare partners to support enterprise data integration initiatives.
• Participate in architecture discussions and recommend best practices for healthcare data engineering.

Required Qualifications

• Bachelor's degree in Computer Science, Information Technology, Engineering, or a related field (or equivalent experience).
• 5–8+ years of experience as a Data Engineer, Integration Engineer, or Healthcare Data Engineer.
• Strong expertise with HIPAA X12 EDI transaction standards, including:
  • 837 (Professional, Institutional, Dental)
  • 277CA
  • 999
  • 834
  • 835
• Hands-on experience with Medicaid encounter processing and state Medicaid submissions.
• Experience implementing CMS encounter regulations, schema updates, and compliance changes.
• Strong experience with Databricks, PySpark, Delta Lake, and SQL Server.
• Experience with healthcare claims validation platforms such as HIPAA Suite or similar EDI processing tools.
• Strong understanding of:
  • HIPAA regulations
  • PHI security and data privacy
  • SNIP validation levels
  • EDI mapping, loops, segments, and companion guides
• Experience integrating with healthcare clearinghouses such as Availity, Change Healthcare, or similar platforms.
• Excellent troubleshooting, analytical, and problem-solving skills.

Preferred Qualifications

• Experience with Azure Databricks or other cloud-based data engineering platforms.
• Knowledge of healthcare interoperability standards such as FHIR and HL7.
• Experience with encounter error remediation and state-specific Medicaid edit codes.
• Background supporting Medicaid Managed Care, Medicare Advantage, or Accountable Care Organization (ACO) environments.
• Experience building automated reconciliation, validation, and quality assurance frameworks for healthcare EDI transactions.
• Familiarity with CI/CD pipelines and DevOps practices for data engineering.

Technical Skills

• Databricks
• PySpark
• Delta Lake
• SQL Server
• T-SQL
• Azure Databricks (Preferred)
• HIPAA X12 EDI
• Medicaid Encounters
• CMS Encounter Processing
• HIPAA Suite (or equivalent)
• ETL / ELT Development
• Data Validation & Reconciliation
• Healthcare Claims Processing
• Azure (Preferred)

What You'll Bring

• Strong ownership mindset with the ability to work independently on complex technical initiatives.
• Excellent communication and collaboration skills across technical and business teams.
• Passion for building scalable, reliable, and compliant healthcare data solutions.
• Commitment to delivering high-quality data engineering solutions in a fast-paced healthcare environment.

Why Join Us?

Join a collaborative team where you'll help build mission-critical healthcare data platforms that support millions of healthcare transactions. You'll work with modern data technologies, contribute to large-scale integration initiatives, and play a key role in ensuring secure, compliant, and high-quality healthcare data processing.

NationsBenefits is an Equal Opportunity Employer.