Principal Claims Policy 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 directly with providers on claims policies and disputes
• Lead the Payment Policy Committee and provide policy recommendations
• Review provider contracts for compliance and operational feasibility
• Make adjudication decisions on complex claims and set policy precedents

Required Qualifications

• 10+ years of claims expertise in U.S. healthcare and Medicare Advantage
• Extensive experience in claims policy and adjudication at a large-scale payer
• Strong functional expertise in Medicare Advantage health plan operations
• Expertise in medical coding (CPT, HCPCS Level II, ICD 10 CM/PCS)
• Proficiency with technology and AI tools for claims and policy analysis