Claims Subject Matter Expert (Managed Care)

Position Responsibilities

• Conduct comprehensive review and analysis of current-state claims operations, including people, processes, and supporting systems, to identify gaps, inefficiencies, and improvement opportunities.
• Evaluate the end-to-end claims lifecycle (intake, adjudication, pricing, editing, auditing, and payment), with a focus on identifying upstream root causes of pends, denials, and rework.
• Develop a strategic roadmap to transition from current state to a corrected, optimized future-state operating model, including defined milestones, priorities, and measurable outcomes.
• Lead and support implementation of transformation initiatives, ensuring effective execution across people, process, and technology.
• Serve as a hands-on leader, capable of operating at both a strategic and execution level, including direct engagement in analysis, solution validation, and implementation activities.
• Optimize claims workflows to improve accuracy, turnaround times, auto-adjudication rates, and first-pass resolution, while reducing administrative costs and rework.
• Analyze claims data and operational metrics to identify trends, root causes, and actionable insights that drive performance and quality improvements.
• Interpret provider contracts to ensure accurate claims adjudication, reimbursement, and alignment with contractual terms.
• Support configuration, optimization, or implementation of core claims platforms (e.g., Facets, QNXT, HealthRules or similar systems).
• Prepare for and support internal and external audits (e.g., CMS, state regulatory, financial), including remediation planning and execution.
• Develop and enhance claims-related policies, procedures, and standard operating models aligned with best practices.
• Collaborate cross-functionally (e.g., Enrollment, Provider Network, Medical Management, Finance, Compliance, IT) to resolve issues and improve end-to-end performance.
• Provide subject matter expertise in payment integrity, including identification and mitigation of fraud, waste, and abuse (FWA).
• Support oversight of vendors and delegated entities (e.g., TPAs), ensuring performance, compliance, and accountability.
• Deliver clear reporting and insights to stakeholders, including executive-level summaries of performance, risks, and transformation progress.

Position Qualifications

• Proficiency managing complex work in challenging environments through the alignment of resources and prioritization of efforts to ensure on time, in scope project and/or strategic delivery.
• Managed care industry expertise in trends, innovation, operations, financing, costs, requirements, performance and outcomes.
• New product/market design and implementation in the Commercial, Medicare, Medicare Advantage, Medicaid or associated lines of business.
• New population identification, program design and implementation to support needs/requirements of increasingly complex memberships while ensuring stable operations and target outcomes.
• Strong understanding of legal and regulatory frameworks, healthcare administration models, and internal audit procedures.
• Work closely with concepts such as HIPAA, as well as State’s Department of Insurance, Federal and State Health and Human Services, CMS, NCQA, and URAC, to ensure compliance with complex regulatory structures.
• Strategic thinker with ability to produce and manage system-wide change through influence and persuasion.
• Knowledge of project management principles, methods, and techniques.
• Ability to organize, prioritize, and manage multiple complex projects.
• Excellent communication skills both written and oral.
• High proficiency with core office software (Excel, Word, and PowerPoint). Visio skills preferred.
• Experience: Bachelor’s Degree in Healthcare Administration or related field, Master’s degree preferred. 5+ years progressive leadership experience in health plan operations, delivering results and managing teams and projects in a health plan setting and/or consulting environment; driving complex, multi-faceted, multi-site, application/operational change/improvement programs and activities. 3+ years of management experience in a government payor environment at a Director or equivalent level with experience in multiple lines of business (Medicare, Medicaid, Healthcare Exchange, etc).