Role & responsibilities

- Act as the Subject Matter Expert (SME) for end-to-end claims adjudication, handling complex, escalated and high-value claims

- Review and adjudicate claims accurately as per policy terms, coverage rules, client guidelines and regulatory requirements

- Provide guidance, clarifications and floor support to processors and adjudicators on complex claim scenarios

- Conduct quality audits and root cause analysis on errors; share feedback and drive corrective actions

- Identify process gaps, fraud/waste/abuse patterns and recommend improvements

- Support training and upskilling of new hires and existing team members; prepare SOPs and job aids

- Ensure adherence to TAT, accuracy and compliance targets (SLA/KPI)

- Coordinate with clients, operations, quality and compliance teams to resolve queries and escalations





- Stay updated on policy changes, regulatory updates (HIPAA etc.) and communicate them to the team

Preferred candidate profile

- 4 to 8 years of relevant experience in claims adjudication (Health / Insurance / US Healthcare)

- Robust knowledge of claims lifecycle, benefits, coverage, coordination of benefits (COB), pricing and denial management

- Good understanding of medical terminology, CPT/ICD/HCPCS coding and EOB/ERA (preferred)

- Prior experience as SME, Subject Matter Specialist, Senior Associate or Team Lead is preferred

- Hands-on experience with claims platforms such as FACETS, QNXT, HealthEdge or similar (advantage)

📌 SME Claims Adjudication (Chennai)
🏢 Manning Consulting
📍 Chennai