Claims Subject Matter Expert (SME) - Healthcare
Experience: 3-5 Years
Location: Bengaluru, India (CHSI)
Function: Healthcare Operations - Claims Administration

Role Summary

The Claims SME serves as the process and domain expert for healthcare claims operations, providing advanced adjudication expertise, guidance to frontline teams, and support to supervisors and managers. This role ensures first-time-right claim outcomes, drives quality and compliance, supports training and audits, and acts as a key escalation and client-support resource across claims workflows.

Key Responsibilities

Advanced Claims Adjudication Expertise
- Handle complex, high-dollar, and exception claims across skilled and/or institutional claim types.
- Provide expert guidance on:
- Coverage determinations and benefit interpretation
- Medical necessity, coding edits, bundling/unbundling, COB, and payment policies
- Appeals, reconsiderations, adjustments, and reprocessing scenarios

SME Support, Escalations Coaching




- Act as the first point of contact for escalations from Claims Representatives and Supervisors.
- Support frontline staff with real-time guidance, case walkthroughs, and decision validation.
- Coach team members to improve accuracy, documentation quality, and adjudication confidence.
- Contribute to knowledge articles, FAQs, job aids, and SOP updates.

Quality, Compliance Audit Support
- Own and support quality performance for assigned processes/LOBs.
- Participate in internal/external audits, client calibrations, and compliance reviews.
- Perform root cause analysis of errors, denials, and rework trends; recommend corrective actions.
- Ensure strict adherence to HIPAA/PHI, data privacy, and internal controls.

Process Excellence Continuous Improvement
- Identify process gaps, policy ambiguities, and system issues impacting claim outcomes.
- Partner with Quality, Training, and Operations teams on:
- Refresher trainings
- SOP enhancements
- Productivity and quality improvement

📌 Claims Senior Representative (Bengaluru)
🏢 The Cigna Group
📍 Bengaluru