SME-Claims HC

Job Summary

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.

Responsibilities

• Review and adjudicate complex health care claims with precision to ensure accurate payment decisions that align with payer policies and contractual terms while minimizing financial leakage and rework.
• Apply expert understanding of HIPAA regulations to safeguard member data throughout claims handling activities and to support compliant documentation that can withstand internal and external audits.
• Analyze claim patterns across provider and payer data to identify root causes of denials or delays and recommend targeted process improvements that enhance turnaround time and payment accuracy.
• Collaborate with operations teams in night shift hybrid model to resolve claim escalations in a timely manner and provide clear guidance that enables consistent decisions across the claims portfolio.
• Document detailed adjudication rationales in claim systems so that downstream teams and external stakeholders can easily understand the basis for payment or denial decisions.
• Partner with provider relations and payer business teams to clarify benefit designs coding rules and reimbursement methodologies so that complex claim scenarios are processed correctly the first time.
• Conduct quality reviews of processed claims to verify adherence to standard operating procedures and provide structured feedback that improves team accuracy and efficiency.
• Contribute subject matter input to updates of policies and procedures related to claims adjudication HIPAA compliance and provider payer workflows to keep documentation aligned with regulatory and business changes.
• Support training activities by explaining complex claim rules and provider payer scenarios in simple terms so that new team members can quickly become productive.
• Use claim processing tools and reporting dashboards to monitor night shift workloads and prioritize items that have high financial impact or customer sensitivity.
• Engage with business analysts and technology teams to validate system configuration changes that affect claims adjudication and to highlight potential risks before deployment.
• Provide insights from day to day claim handling that guide product and benefit design improvements which improve member experience and reduce unnecessary provider friction.
• Coordinate with customer service teams to supply clear claim level explanations that help reduce repeat inquiries and support a more transparent experience for members providers and payer partners.
  
  

• Possess proven experience in health care claims adjudication with at least three years handling end to end processing of medical or hospital claims in a provider and payer context.
• Demonstrate strong practical knowledge of HIPAA privacy and security requirements as applied to real world claims workflows documentation practices and system usage.
• Bring hands on exposure to both provider side and payer side environments enabling balanced decision making that respects contractual terms network rules and member benefits.
• Exhibit proficiency with common claim platforms spreadsheets and reporting tools to research complex cases validate calculations and summarize findings for stakeholders.
• Show excellent written and verbal communication skills that support clear explanations of claim outcomes and effective collaboration across distributed hybrid teams.
• Display strong analytical and problem solving abilities with attention to detail that ensures accurate handling of high volume claims under night shift timelines.
• Adapt comfortably to a hybrid work model and night shift schedule while maintaining consistent productivity quality standards and responsiveness to team needs.