SME-Claims HC

About the role

Serve as a subject matter expert in health care claims with a focus on claims adjudication and regulatory compliance in a hybrid night shift work model. Apply deep knowledge of HIPAA rules and both provider and payer operations to resolve complex claim scenarios reduce leakage and improve accuracy. Collaborate across teams to enhance claim workflows that support better outcomes for members and partners.

What you'll do

• Review and adjudicate complex health care claims with precision to ensure accurate payment decisions that align with payer policies and contractual terms while…
• Apply expert understanding of HIPAA regulations to safeguard member data throughout claims handling activities and to support compliant documentation that can withstand…
• Analyze claim patterns across provider and payer data to identify root causes of denials or delays and recommend targeted process improvements that enhance turnaround…
• Collaborate with operations teams in night shift hybrid model to resolve claim escalations in a timely manner and provide clear guidance that enables consistent…
• Document detailed adjudication rationales in claim systems so that downstream teams and external stakeholders can easily understand the basis for payment or denial…

What you need

• Claims processing
• Reporting
• Excel
• Compliance
• Customer service
• Audit

Good to have

• SOP writing