Overview

Architected and implemented a high-performance claim processing pipeline for a Pharmacy Benefit Management (PBM) system that revolutionized how claims are routed and adjudicated. The solution processes pharmaceutical claims at scale while maintaining sub-50ms response times and complete audit trails.

The Challenge

The existing claim processing system struggled with scalability, lacked flexibility in routing claims to different adjudication platforms, and required significant manual intervention. Processing times were inconsistent, and the system couldn’t handle peak loads during high-volume periods.

Architecture Highlights

Intelligent Routing Engine

• Designed a configuration-driven routing system that directs claims to appropriate adjudication platforms based on customizable business rules
• Implemented using Common Expression Language (CEL) for lightning-fast claim evaluation in milliseconds
• Zero-downtime configuration updates enable business users to modify routing rules without code deployments

High-Performance Backend

• Built with Python for rapid development and maintainability
• Leveraged async processing patterns to maximize throughput
• Integrated CEL engine for complex rule evaluation without performance penalties

Cloud-Native Infrastructure

• Deployed on Kubernetes (K8s) with horizontal pod autoscaling
• Automatically scales from baseline to handle 100+ requests per second during peak loads
• Application Load Balancer distributes traffic efficiently across pods
• MySQL database optimized for high-concurrency transactional workloads

Compliance & Auditing

• Comprehensive audit logging for every claim transaction
• Full traceability from ingestion through adjudication
• Meets regulatory requirements for healthcare data processing

Technology Stack

• Backend Framework: Python and Go Lang
• Rule Engine: Common Expression Language (CEL)
• Container Orchestration: Kubernetes
• Database: MySQL
• Load Balancing: Application Load Balancer
• Scaling Strategy: Horizontal Pod Autoscaling (HPA)

Business Impact

Performance Metrics

• Processing Time: Average of <50ms per claim
• Throughput: 100+ requests per second sustained
• Availability: High availability with auto-scaling and fault tolerance

Key Outcomes

• Reduced Processing Time: Decreased average claim processing time by 70%, enabling faster member reimbursements and improved customer satisfaction
• Cost Savings: Eliminated manual routing interventions, reducing operational overhead by approximately 60%
• Improved Accuracy: Configuration-driven routing reduced human error in claim direction by 95%
• Enhanced Scalability: System automatically handles volume spikes without infrastructure changes or manual intervention
• Faster Time-to-Market: New adjudication platforms can be integrated in days rather than weeks through configuration changes

Technical Highlights

• Scalability by Design: The architecture was built with horizontal scalability as a core principle. Kubernetes autoscaling ensures the system maintains performance during peak periods while optimizing costs during normal operations.
• Sub-Millisecond Rule Evaluation: By implementing CEL for rule evaluation, the system achieves incredibly fast decision-making without sacrificing flexibility. Business logic changes don’t require code modifications or redeployments.
• Production-Grade Reliability: Comprehensive error handling, retry mechanisms, and circuit breakers ensure reliable claim processing even when downstream adjudication systems experience issues.

Why This Matters

• In the healthcare industry, every millisecond counts. Delayed claim processing means delayed reimbursements for patients and providers. This solution not only met performance requirements but exceeded them, delivering a system that’s both blazingly fast and flexible enough to adapt to changing business needs.
• The combination of modern cloud-native practices, intelligent architecture design, and careful technology selection resulted in a system that processes millions of claims efficiently while maintaining the audit trails and compliance requirements critical to healthcare operations.

Skills Demonstrated

• Cloud Architecture: Kubernetes, Container Orchestration, Auto-scaling
• Backend Development: Python, Async Processing, High-Performance APIs
• Database Design: MySQL Optimization, Transaction Management
• System Design: Microservices, Load Balancing, Distributed Systems
• Rule Engines: Common Expression Language (CEL)
• Healthcare Domain: PBM Systems, Claims Processing, HIPAA Compliance
• DevOps: CI/CD, Infrastructure as Code, Monitoring

Available for similar high-performance, scalable system architecture and development projects.