Claims Specialist

Job Description: Calls and Claims Subject Matter Expert (SME)

Position Summary

The Calls and Claims Subject Matter Expert (SME) serves as a key operational resource responsible for supporting claims performance, call quality, call and claim auditing, compliance adherence, issue identification, and continuous improvement. This role provides subject matter expertise across medical and dental claims, claim adjustments, benefits and eligibility inquiries, member and provider service interactions, escalation handling, vendor performance, audit execution, and operational reporting. The SME is expected to translate claims trends, call drivers, audit findings, and performance data into actionable recommendations that improve claims accuracy, strengthen controls, reduce recurring defects, and support leadership decision-making.

Key Responsibilities

· Provide subject matter expertise on end-to-end claims operations and related call support, including claim intake, adjudication, adjustments, benefit interpretation, inquiry resolution, call documentation, escalation handling, quality monitoring, and post-resolution follow-up.

· Evaluate whether claims and call representatives are applying approved procedures consistently, using accurate benefit and claim information, and resolving member or provider inquiries within expected service and quality standards.

· Perform call and claim audits to validate accuracy, compliance, documentation quality, benefit application, adjustment handling, inquiry resolution, and adherence to approved workflows.

· Analyze operational metrics such as claims inventory, aging, accuracy, adjustment volume, rework, financial impact, service level, average speed of answer, abandonment rate, first-call resolution, repeat call trends, escalation volume, and avoidable contact drivers.

Quality and Compliance Oversight

· Review claim samples, adjustment activity, audit results, call recordings, transcripts, complaints, escalation data, and operational reports to identify claims quality trends, documentation gaps, compliance risks, financial exposure, and improvement opportunities.

· Evaluate claims, calls, and supporting documentation against established quality, compliance, privacy, contractual, financial accuracy, and customer experience standards.

· Conduct targeted and random audits of claims, calls, adjustments, escalations, and supporting documentation to confirm compliance with quality standards, contractual requirements, regulatory expectations, and internal controls.

· Identify potential regulatory, contractual, privacy, service, or reputational risks and ensure appropriate escalation, documentation, and follow-up.

· Document audit results, assign severity or risk levels as appropriate, identify recurring error patterns, and recommend corrective actions to improve claims accuracy and call handling consistency.

· Support quality calibration activities to promote consistent interpretation of claims audit criteria, call evaluation standards, adjustment requirements, and corrective action expectations.

Reporting, Analysis, and Continuous Improvement

· Conduct structured root-cause analysis to determine whether identified claims or call issues are related to training, process design, system configuration, benefit interpretation, documentation, vendor execution, or control gaps.

· Develop executive and operational reporting that summarizes performance results, quality findings, root causes, corrective actions, risk indicators, and trend movement over time.

· Recommend measurable, time-bound, and owner-assigned corrective actions supported by ongoing monitoring and validation.

Training, Coaching, and Knowledge Support

· identified performance gaps, documentation deficiencies, service behaviors, claim handling requirements, and compliance expectations.

· Translate claims audit findings, call trends, and operational data into targeted training, process clarification, system review, or corrective action recommendations.

· Partner with internal teams and vendors to promote consistent process execution and improve member and provider service outcomes.

Stakeholder Communication

· Communicate findings, risks, recommendations, and required follow-up actions to leadership, operational teams, vendors, and external stakeholders using clear, objective, and data-supported language.

· Prepare leadership-ready summaries that connect claims performance, call trends, quality findings, operational risk, financial impact, and member or provider experience impacts.

· Facilitate vendor oversight discussions, communicate performance expectations, monitor corrective actions, and validate remediation effectiveness.

Required Qualifications

· Minimum of 5 years of experience in claims operations, claims quality assurance, claims support, call center operations, member services, provider services, customer experience oversight, or a related operational role.

· Experience with medical and/or dental claims, eligibility, benefits, prior authorization, provider inquiries, member inquiries, adjustments, appeals, grievances, and escalation handling.

· Strong understanding of claims processing workflows, claim accuracy standards, adjustment requirements, call center performance metrics, quality audit practices, documentation standards, escalation protocols, and customer experience expectations.

· Ability to analyze claims data, adjustment activity, claim samples, call recordings, transcripts, audit results, complaints, and operational reports to identify trends, risks, financial exposure, and improvement opportunities.

· Experience conducting call and claim audits, documenting findings, identifying root causes, validating corrective actions, and presenting audit outcomes to operational leaders.

· Strong written and verbal communication skills with the ability to summarize complex operational issues in a clear, concise, and leadership-ready format.

Preferred Qualifications

· Experience in a healthcare payer, benefits administration, federal program, or vendor oversight environment.

· Understanding of federal program requirements, healthcare regulations, contractual service expectations, HIPAA, privacy requirements, and audit-ready documentation standards.

· Experience performing claims audits, call audits, oversight reviews, sample validation, trend analysis, root-cause analysis, and quality calibration activities.

· Experience using or interpreting outputs from call recording systems, call monitoring platforms, quality audit tools, workforce management systems, CRM or case management systems, dashboards, and reporting tools.

· Knowledge of continuous improvement methodologies, root-cause analysis, corrective action tracking, and control validation practices.

Key Competencies

· Claims quality analysis

· Call quality review

· Problem solving

· Root-cause analysis

· Call and claim auditing

· Coaching and development

· Data interpretation

· Executive reporting

· Customer experience management

· Vendor oversight and accountability

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