Principal Claims Expert

A company is looking for a Principal Claims & Payments Expert to serve as a lead authority on claims-related policy matters.

Key Responsibilities

Interface with providers on claims policies and disputes, ensuring clear communication of complex claims

Lead the Payment Policy Committee, providing policy recommendations that align with compliance and operational goals

Review complex claims and provider contracts, making adjudication decisions and setting policy precedents

Required Qualifications

10+ years of deep claims expertise in U.S. healthcare, Medicare Advantage, and revenue cycle management

Mastery of claims policy and adjudication from extensive experience at a large-scale payer

Strong functional expertise in Medicare Advantage health plan operations and financial drivers

Expertise in medical coding (CPT, HCPCS Level II, ICD 10 CM / PCS) and its impact on payment integrity

Proficiency in technology, including AI and automation tools for claims and policy analysis