M&R Claims Processor / Subject Matter Expert (SME)

Role: M&R Claims Processor / Subject Matter Expert (SME)
Years of Experience: 5–10+ Years (US Healthcare – Claims Processing, M&R preferred)

Short Description
We are looking for a highly experienced M&R Claims Processor / SME with strong expertise in UHC claims adjudication and business workflows, capable of handling end-to-end claims processing, conducting quality reviews, training team members, and performing analytical deep dives to improve claims accuracy and operations.

Primary Responsibilities
Claims Processing & Adjudication
* Strong knowledge of COSMOS/CPA applications
* Solid understanding of the M&R line of business
* Familiarity with both facility and physician claims
* Comprehensive understanding of the end-to-end claims lifecycle
* Knowledge of appeals processes is preferred
* Understanding of member enrollment processes and provider contracts
Quality Review & Validation
* Review processed claims for accuracy and compliance
* Conduct audits and peer reviews
* Identify defect trends and perform root cause analysis (RCA)
* Recommend corrective and preventive actions
SME / Domain Expertise
* Act as M&R LOB SME with strong UHC business understanding
* Interpret policies and translate into operational guidelines
* Support complex claims adjudication scenarios and escalations
Training & Knowledge Transfer
* Train and mentor team members on:
   * Claims adjudication
   * UHC workflows and systems
* Create job aids, SOPs, and training documentation
Analysis & Process Improvement
* Perform data analysis on:
   * Claim denials
   * Processing accuracy
   * Operational gaps
* Support process improvements and automation initiatives

Must Have Skills
* Strong experience in UHC M&R Claims Processing
* Hands-on expertise in:
    * Claims adjudication
    * Reimbursement and policy interpretation
* Experience working with COSMOS CPA/ ICES / claims systems
* Strong analytical and problem-solving skills
* Experience in claims review and quality validation
* Ability to train and mentor junior resources

Nice To Have Skills
* Exposure to E&I or C&S domain
* Experience in process improvement / automation initiatives

Key Competencies
* Strong UHC domain expertise
* Detail-oriented with strong quality focus
* Excellent communication and stakeholder management skills
* Ability to work independently and in a team environment