SME-Claims HC

About the Role

Serve as a subject matter expert in health care claims adjudication with a focus on payer and provider operations. Utilize 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.

Key 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.
• 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.
• Collaborate with payer and provider operations teams to clarify benefit designs, coding interpretations, and contract terms.
• Document detailed claim adjudication rationales and maintain clear audit-ready records.
• Investigate claim-related issues escalated by internal teams and external partners, provide clear resolutions, and communicate findings.
• Monitor key performance indicators related to claims turnaround times, payment accuracy, and rework rates, and contribute insights for continuous improvement.
• Support implementation of process enhancements by validating rule changes, testing calculation logic using structured MS Excel models, and sharing structured feedback.
• Provide subject matter expertise to colleagues by clarifying claim policies, explaining payer and provider-specific nuances, and encouraging consistent application of adjudication standards.
• Coordinate with quality assurance and compliance functions to identify patterns of recurring claim errors, assist in root cause analysis, and help design preventive controls.
• 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.
• Maintain up-to-date awareness of changes in payer guidelines and provider billing practices and translate these developments into practical adjudication updates.
• Share data-driven insights from claims analysis that inform strategic decisions.

Requirements & Tech Stack

• MS Excel (advanced functions: lookups, pivot-based analysis)

Qualifications

• Demonstrated strong proficiency in MS Excel, including the ability to manage large health care data sets and perform detailed analyses.
• Hands-on experience in claims adjudication within health care operations, applying payer policies and provider billing standards.
• Solid knowledge of payer environments, including plan structures, benefit designs, and reimbursement models.
• Solid understanding of provider workflows, including common billing practices, coding patterns, and documentation requirements.
• 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.
• Ability to work effectively in a hybrid model with night shift schedules, maintaining productivity, collaboration, and responsiveness.

Certifications

• Preferred: Certification in health care claims or medical billing (e.g., AAPC CPC or AHIP related claims certification).