Principal Claims Expert

Job Summary

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