SME Claims Adjudication

Role & responsibilities

• Act as the Subject Matter Expert (SME) for end-to-end claims adjudication, handling complex, escalated and high-value claims
• Review and adjudicate claims accurately as per policy terms, coverage rules, client guidelines and regulatory requirements
• Provide guidance, clarifications and floor support to processors and adjudicators on complex claim scenarios
• Conduct quality audits and root cause analysis on errors; share feedback and drive corrective actions
• Identify process gaps, fraud/waste/abuse patterns and recommend improvements
• Support training and upskilling of new hires and existing team members; prepare SOPs and job aids
• Ensure adherence to TAT, accuracy and compliance targets (SLA/KPI)
• Coordinate with clients, operations, quality and compliance teams to resolve queries and escalations
• Stay updated on policy changes, regulatory updates (HIPAA etc.) and communicate them to the team

Preferred candidate profile

• 4 to 8 years of relevant experience in claims adjudication (Health / Insurance / US Healthcare)
• Strong knowledge of claims lifecycle, benefits, coverage, coordination of benefits (COB), pricing and denial management
• Good understanding of medical terminology, CPT/ICD/HCPCS coding and EOB/ERA (preferred)
• Prior experience as SME, Subject Matter Specialist, Senior Associate or Team Lead is preferred
• Hands-on experience with claims platforms such as FACETS, QNXT, HealthEdge or similar (advantage)