SME-Claims HC

Job Summary

Serve as a subject matter expert in health care claims adjudication with a focus on payer and provider operations using advanced MS Excel skills to analyze claim data and resolve complex issues in a hybrid night shift role. Contribute to improving claims accuracy member satisfaction and cost efficiency while collaborating with cross functional teams to optimize end to end claims processes.

Responsibilities

• Analyze health care claim batches with meticulous attention to payer and provider rules to ensure accurate adjudication and timely resolution of claims while working primarily in a night shift hybrid model
• Review complex claim scenarios and apply adjudication guidelines to identify discrepancies adjust payments and minimize financial leakage for the organization and its stakeholders
• Utilize advanced MS Excel functions such as lookups and pivot based analysis to interpret large data sets spot claim processing trends and propose corrective actions that improve operational performance
• Collaborate with payer and provider operations teams to clarify benefit designs coding interpretations and contract terms to support precise claim decisions and consistent application of policies
• Document detailed claim adjudication rationales and maintain clear audit ready records that support compliance with internal standards and external regulatory expectations
• Investigate claim related issues escalated by internal teams and external partners provide clear resolutions and communicate findings that strengthen trust and transparency in claims processing
• Monitor key performance indicators related to claims turnaround times payment accuracy and rework rates and contribute insights that guide continuous improvement initiatives across the claims lifecycle
• Support implementation of process enhancements by validating rule changes testing calculation logic using structured MS Excel models and sharing structured feedback that reduces defects in production
• Provide subject matter expertise to colleagues by clarifying claim policies explaining payer and provider specific nuances and encouraging consistent application of adjudication standards in daily work
• Coordinate with quality assurance and compliance functions to identify patterns of recurring claim errors assist in root cause analysis and help design preventive controls that safeguard members and providers
• Engage with cross functional claims and operations teams to align day to day activities with the company mission of delivering fair accurate and timely claim outcomes that positively impact patient access and affordability
• Maintain up to date awareness of changes in payer guidelines and provider billing practices and translate these developments into practical adjudication updates that support organizational resilience
• Contribute to a culture of accountability and continuous learning by sharing data driven insights from claims analysis that inform strategic decisions and enhance the company contribution to the wider health care ecosystem

Qualifications

• Demonstrate strong proficiency in MS Excel including ability to manage large health care data sets and perform detailed analyses that support reliable and efficient claims adjudication
• Bring hands on experience in claims adjudication within health care operations applying payer policies and provider billing standards to ensure accurate benefit determination and payment calculation
• Possess solid knowledge of payer environments including plan structures benefit designs and reimbursement models that influence day to day decisions in claims processing work
• Possess solid understanding of provider workflows including common billing practices coding patterns and documentation requirements that affect claim submission and adjudication outcomes
• Show proven experience of two to four years in health care claims roles with consistent performance in accuracy turnaround time and adherence to documented adjudication guidelines
• Exhibit ability to work effectively in a hybrid model with night shift schedules maintaining productivity collaboration and responsiveness across both virtual and on site settings

Certifications Required

Preferred certification in health care claims or medical billing such as AAPC CPC or AHIP related claims certification