SME (Subject Matter Expert)

Summary

The SME is the process and claims knowledge anchor for the Life, AD&D and Annuity Claims team. The role resolves complex claims, guides processors, own SOPs, training and quality and partners with the client across shores to meet SLA, TAT and quality targets. The SME also identifies opportunities to streamline, standardize and automate the process.

Roles and Responsibilities

1. Expertise claims and complex case handling

• Maintain strong understanding of client plan provisions, product rules, processing guidelines and SLA metrics.
• Manually process complex Life, AD&D and Annuity claims that need plan knowledge, analysis and interpretation, including benefit calculations.
• Research complex or exception cases, analyze fact patterns, apply plan provisions and recommend resolutions.
• Act as the first point of escalation for processor queries and clarify guidelines in real time.

2. Quality, Audit and Compliance

• Perform quality checks and audits on processed claims, share feedback and track error trends
• Run root cause analysis (RCA) on errors and repeat issues, drive corrective and preventive actions
• Ensure adherence to SOPs, HIPPA, data privacy and security standards and the Code of Conduct.
• Support client and internal audits with accurate documentation.

3. Training, Coaching & Onboarding

• Deliver classroom and on the job training for new joiners
• Support certification and proficiency phases, identify non performers and run remediation
• Identify training needs and coach processors proactively
• Run knowledge refreshers on process, guideline and system changes.

4. Documentation and knowledge Management

• Create and maintain SOPs, job aids, process maps and FAQs
• Verify and implement updates arising from client change orders
• Document task and workflow analysis clearly so the wider team can follow it

5. Operations and Delivery Support

• Support daily work allocation, inventory and priority management with the Team Lead, including backlog and ongoing volume
• Help the team meet APT, daily throughput
• Participate in and contribute to daily huddles and status meetings
• Prepare and hoc reports and MIS for service delivery needs

6. Client and Stakeholder Partnership

• Be the day-to-day process contact for client and onshore teams on claims queries and clarifications
• Build and leverage partnerships across shores
• Listen to stakeholders and keep communication clear across channels

7. Continuous Improvement

• Identify process delays, quality gaps, and effort reduction opportunities (e.g. checklist, validation checkpoints, automation candidates)
• Recommend and help implement solutions with Team Managers and the Practice Manager
• Support APT validation and productivity analysis during pilot and steady state

Required Experience

• 5-8 years in claims or benefits operations, with at least 3-4 years in US Life, AD&D or Annuity claims
• US healthcare and benefits domain knowledge (e.g. beneficiary, policy, riders, eligibility, claim adjudication, HIPPA)
• Proven experience in complex claims, calculations and exception handling
• Prior experience in quality audits, training or coaching, or as a process trainer or SME
• Good MS Office skills (Excel, Word, PowerPoint), strong verbal and written communication

Work Conditions

• Shift : Primarily US time zone hours (night shift IST), five days a week, flexibility to rotate shifts as business requires
• Work mode : Work from Office