Data Engineer, Healthcare Claims (US Based)

Protera Health is seeking a Data Engineer, Healthcare Claims for a 3-6 month contract engagement with potential for full-time extension focused on building the claims data infrastructure that supports our medical economics, actuarial analysis, client reporting, and value-based care programs.

Candidates must have significant hands-on experience transforming raw health plan medical claims data and enrollment files into reliable, normalized datasets that Protera can use to evaluate healthcare utilization, medical expenditures, savings, and financial performance.

You will be responsible for mapping partner-specific formats, fields, codes, and definitions into a standardized Protera claims model. The goal is to create a common reporting layer that supports consistent analysis across partners without rebuilding complex claims logic for every report.

This is a hands-on role. You will design the claims architecture, build production-ready pipelines and data models, validate the results, and perform claims analytics in Google BigQuery directly. You will work closely with Protera’s Chief Actuary and collaborate with our Technology, Finance, Clinical, and Operations teams.

Key Responsibilities

Claims Processing and Data Quality

• Build reliable processes for ingesting and validating historical and incremental medical and pharmacy claims along with related enrollment files.
• Process full data refreshes, recurring files, and retroactive claims activity accounting for adjusted, reversed, and replacement claims.
• Reconcile incoming claims against previously processed data and investigate discrepancies.
• Implement automated checks for completeness, duplicates, schema changes, unexpected volumes, financial reconciliation, and data freshness.

Claims Normalization and Data Modeling

• Design a standardized claims data model that can support multiple health plans and employer partners.
• Map partner-specific file structures, fields, values, and definitions into Protera’s common claims structure.
• Connect claims with member eligibility, attribution, enrollment, provider, and clinical data.
• Maintain reusable classification logic for ICD-10, CPT, HCPCS, DRG, revenue, place-of-service, and pharmacy codes.
• Document source-to-target mappings, business rules, assumptions, data lineage, and partner-specific exceptions.

Medical Economics and Reporting

• Translate actuarial and medical economics requirements into scalable datasets and reporting logic.
• Apply Protera’s MSK inclusion and exclusion criteria consistently across health plan populations incorporating customer service type and exclusion criteria definitions.
• Ensure reported results are traceable to source data and supported by clearly documented methodologies.

Cross-Functional Execution

• Serve as a technical subject-matter expert for health plan claims and enrollment data.
• Partner with Protera’s Chief Actuary to translate actuarial requirements into reliable technical solutions.
• Collaborate with Protera’s data and operational teams on shared definitions for member identity, eligibility, attribution, and enrollment.
• Explain complex claims methodologies and findings clearly to technical and nontechnical stakeholders.
• Support the evaluation of claims data requirements for current and prospective health plan partnerships.

Required Qualifications

• A Bachelor’s degree in Computer Science, Health Informatics, Information Systems or a related technical discipline.
• 7+ years of experience in healthcare claims data engineering supporting medical economics and actuarial departments.
• Strong understanding of claims adjudication, including adjusted, replacement, reversed, denied, and voided claims.
• Experience integrating claims with member eligibility, attribution, and enrollment data.
• Knowledge of healthcare coding systems, including ICD-10, CPT, HCPCS, DRG, revenue, place-of-service, and pharmacy codes.
• Experience with BigQuery, Google Cloud Platform, Cloud Storage, PostgreSQL, and Terraform.
• Advanced SQL skills.
• Experience designing and validating analytical data models for large healthcare datasets.
• Ability to translate actuarial, financial, and reporting requirements into production-ready technical solutions.
• Strong judgment, organization, communication, and problem-solving skills.
• Comfortable working independently in a fast-moving environment where priorities and responsibilities evolve.
• Hands-on, accountable, collaborative, and willing to personally investigate and resolve data problems.

Preferred Qualifications

• Experience with musculoskeletal, orthopedic, rehabilitation, or pain-related claims analysis.
• Experience developing episodes-of-care methodologies.
• Experience supporting shared-savings, case-rate, bundled-payment, or full-risk contracts.
• Background in digital health, healthcare analytics, or a risk-bearing provider organization.