Healthcare Claims Administration ExpertThis position requires a highly experienced Subject Matter Expert (SME) with deep knowledge of complex healthcare claims administration, payment operations, and regulated health program environments. The SME provides authoritative expertise to help project teams and technical leads understand operational processes, regulatory requirements, contractor interactions, and supporting technologies. The role provides strategic guidance and operational insights to support program performance, compliance, and continuous improvement.
Responsibilities:
Serve as a subject matter expert on large-scale healthcare claims administration, payment operations, and supporting contractor structures.
Advise project teams on operational responsibilities such as claims processing, provider enrollment, appeals, medical review, and coverage determinations.
Analyze claims volumes, provider populations, payment activity, and other operational data to support program evaluation and decision-making.
Provide guidance on relationships and workflows among contractors and other organizations supporting complex healthcare programs.
Support contracting and compliance activities by interpreting applicable procurement requirements, policies, and regulations.
Partner with project managers, analysts, and technical leads to evaluate operations, identify improvement opportunities, and support compliance objectives.
Contribute subject matter expertise to solution development, proposals, requirements analysis, and technical documentation.
Provide guidance on interoperability, data flows, claims processing, and their impact on overall program performance.
Maintain knowledge of relevant regulatory updates, contractual obligations, and operational best practices.
Assist with risk identification and development of operational procedures and playbooks to improve program support and performance.
Qualifications:
Extensive knowledge of healthcare claims administration, payment operations, and complex regulated healthcare environments.
Experience supporting multiple healthcare claim types and related processing workflows.
Strong knowledge of claims adjudication, provider enrollment, appeals, medical review, and coverage determination processes.
Experience with healthcare claims pricing, prospective payment methodologies, fee schedules, or comparable payment systems.
Demonstrated experience supporting large-scale healthcare programs, healthcare contractors, or similarly complex regulated environments.
Strong understanding of relationships and workflows among organizations involved in healthcare claims administration and program operations.
Knowledge of claims system edits, exception or suspense processing, and reporting requirements.
Familiarity with provider and beneficiary or member workflows related to claims processing and payments.
Ability to communicate complex healthcare program, operational, and technical information clearly to diverse stakeholders.
Relevant education, training, certifications, or equivalent practical experience.
Publishing Pay Range: $96.00 – $100.00 HourlyThis is a fully remote role and can be performed from any approved location within the United States.
