Claims Lead Representative

Claims Subject Matter Expert (SME) – Healthcare
Experience: 6–8 Years
Location: Bengaluru, India (CHSI)
Function: Healthcare Operations – Claims Administration

Role Summary

The Claims SME serves as the process and domain expert for healthcare claims operations, providing advanced adjudication expertise, guidance to frontline teams, and support to supervisors and managers. This role ensures first-time-right claim outcomes, drives quality and compliance, supports training and audits, and acts as a key escalation and client-support resource across claims workflows.

Key Responsibilities

Advanced Claims Adjudication & Expertise

• Handle complex, high-dollar, and exception claims across professional and/or institutional claim types.

• Provide expert guidance on:

  • Coverage determinations and benefit interpretation

  • Medical necessity, coding edits, bundling/unbundling, COB, and payment policies

  • Appeals, reconsiderations, adjustments, and reprocessing scenarios

• Ensure accurate application of payer policies, client-specific guidelines, and regulatory requirements.

SME Support, Escalations & Coaching

• Act as the first point of contact for escalations from Claims Representatives and Supervisors.

• Support frontline staff with real-time guidance, case walkthroughs, and decision validation.

• Coach team members to improve accuracy, documentation quality, and adjudication confidence.

• Contribute to knowledge articles, FAQs, job aids, and SOP updates.

Quality, Compliance & Audit Support

• Own and support quality performance for assigned processes/LOBs.

• Participate in internal/external audits, client calibrations, and compliance reviews.

• Perform root cause analysis of errors, denials, and rework trends; recommend corrective actions.

• Ensure strict adherence to HIPAA/PHI, data privacy, and internal controls.

Process Excellence & Continuous Improvement

• Identify process gaps, policy ambiguities, and system issues impacting claim outcomes.

• Partner with Quality, Training, and Operations teams on:

  • Refresher trainings

  • SOP enhancements

  • Productivity and quality improvement initiatives

• Support transition activities, pilot processes, and stabilization for new claim types or clients.

Stakeholder & Client Support

• Support supervisors/managers during client calls, escalations, and performance reviews.

• Provide data-backed insights on claim trends, denial drivers, and improvement opportunities.

• Assist in UAT, system changes, and policy updates impacting claims adjudication.

Required Skills & Competencies

Domain & Technical Expertise

• 6–8 years of hands-on experience in International Healthcare Claims processing/adjudication

• Strong expertise in:

  • End-to-end claims lifecycle

  • Professional (CMS‑1500) and/or Institutional (UB‑04) claims

  • ICD‑10, CPT, HCPCS, modifiers, POS (advanced working knowledge)

  • Denial management, appeals, adjustments, COB, and payment integrity concepts

• Experience working with claims platforms such as Facets, QNXT, Health Edge, EPIC Tapestry, or equivalent.

Behavioural & Leadership Skills

• Strong analytical and decision-making capability

• Ability to influence without authority and coach peers

• Excellent documentation and communication skills

• High ownership, attention to detail, and audit-ready mindset

• Comfortable working in a metric-driven, fast-paced environment

Education & Experience

• Graduate in any discipline (Healthcare/Life Sciences preferred).

• 6–8 years relevant healthcare claims experience with demonstrated SME-level expertise.

• Six Sigma Knowledge and Certification (Yellow/Green Belt)

Performance Measures (KPIs)

• Complex claim accuracy and escalation resolution rate

• Reduction in repeat errors and rework

• Audit and compliance outcomes

• Knowledge contribution (SOPs, job aids, trainings)

• Support effectiveness for team and leadership

Shift & Work Requirements

• Willingness to work US and EU shifts (evening/night) and rotational schedules.

Preferred / Nice-to-Have

• Experience supporting transitions, migrations, or new client onboarding

• Exposure to payment integrity, overpayment recovery, or audit support

• Lean/Six Sigma or continuous improvement exposure

About The Cigna Group

Cigna Healthcare, a division of The Cigna Group, is an advocate for better health through every stage of life. We guide our customers through the health care system, empowering them with the information and insight they need to make the best choices for improving their health and vitality. Join us in driving growth and improving lives.