SME Claims Adjudication

Manning Consulting; Hyderabad, Chennai District, Coimbatore District; On-site; INR 1,200,000 - 1,800,000; Full time

Job summary

Manning Consulting is seeking an experienced SME for end-to-end claims adjudication in a health/insurance domain. You will review and adjudicate complex claims, guide processors, and drive quality and compliance initiatives.

You will lead audits, identify gaps, and support training while staying updated on regulatory changes to ensure accurate resolutions and high service levels.

Qualifications

• 4 to 8 years of relevant experience in claims adjudication (Health / Insurance / US Healthcare).
• Strong knowledge of claims lifecycle, benefits, coverage, coordination of benefits (COB), pricing and denial management.
• Hands-on experience with claims platforms such as FACETS, QNXT, HealthEdge or similar.

Responsibilities

• Act as SME for end-to-end claims adjudication of complex/high-value claims.
• Review and adjudicate claims per policy terms, coverage rules, and regulations.
• Provide floor support to processors and adjudicators on complex scenarios.
• Conduct quality audits and root cause analysis; implement corrective actions.
• Identify process gaps and patterns of fraud/waste/abuse; recommend improvements.
• Support training and upskilling; prepare SOPs and job aids.
• Ensure adherence to TAT, accuracy, and KPI targets.
• Coordinate with clients, operations, quality, and compliance to resolve queries.
• Stay updated on policy/regulatory changes and communicate to the team.

Skills

Claims adjudication

Policy terms

Regulatory compliance

Quality auditing

Process improvement

HIPAA knowledge

Medical terminology

COB understanding

SOPs development

Training & mentoring

Tools

FACETS

QNXT

HealthEdge

Job description

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)
• Strong 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)