M&R Claims Processor / Subject Matter Expert (SME)

Role: M&R Claims Processor / Subject Matter Expert (SME)
Years of Experience: 5?10+ Years (US Healthcare ? Claims Processing, M&R preferred)

Short Description
We are looking for a highly experienced M&R Claims Processor / SME with strong expertise in UHC claims adjudication and business workflows, capable of handling end-to-end claims processing, conducting quality reviews, training team members, and performing analytical deep dives to improve claims accuracy and operations.

Primary Responsibilities
Claims Processing & Adjudication

• Strong knowledge of COSMOS/CPA applications
• Solid understanding of the M&R line of business
• Familiarity with both facility and physician claims
• Comprehensive understanding of the end-to-end claims lifecycle
• Knowledge of appeals processes is preferred
• Understanding of member enrollment processes and provider contracts

Quality Review & Validation

• Review processed claims for accuracy and compliance
• Conduct audits and peer reviews
• Identify defect trends and perform root cause analysis (RCA)
• Recommend corrective and preventive actions

SME / Domain Expertise

• Act as M&R LOB SME with strong UHC business understanding
• Interpret policies and translate into operational guidelines
• Support complex claims adjudication scenarios and escalations

Training & Knowledge Transfer

• Train and mentor team members on:
• Claims adjudication
• UHC workflows and systems
• Create job aids, SOPs, and training documentation

Analysis & Process Improvement

• Perform data analysis on:
• Claim denials
• Processing accuracy
• Operational gaps
• Support process improvements and automation initiatives

Must Have Skills

• Strong experience in UHC M&R Claims Processing
• Hands-on expertise in:
• Claims adjudication
• Reimbursement and policy interpretation
• Experience working with COSMOS CPA/ ICES / claims systems
• Strong analytical and problem-solving skills
• Experience in claims review and quality validation
• Ability to train and mentor junior resources

Nice To Have Skills

• Exposure to E&I or C&S domain
• Experience in process improvement / automation initiatives

Key Competencies

• Strong UHC domain expertise
• Detail-oriented with strong quality focus
• Excellent communication and stakeholder management skills
• Ability to work independently and in a team environment