Subject Matter Expert(Health Claims)

Job Summary:
We are seeking a highly skilled and experienced Subject Matter Expert (Medico) with 7-10 years of
focused experience in the health insurance industry, particularly in claims processing. Understanding
the key KPIs that drive claims processing is critical. The candidate will play a crucial role in bridging the
gap between business needs and IT solutions, contributing to the enhancement of our solution. The
ideal candidate will have a strong techno-functional understanding of the insurance product
benefits, coverages, claims rules, exclusions and fraud analytics and should know about Product
Configuration in the system. Having a comprehensive grasp of Medical Codes ICD, PCS, and CPT
codes would be an additional plus for this role.

Key Responsibilities:

• Collaborate with the Claims head, claims processing and providermanagementteam to gather
and analyse business requirements related to claims processing.

• Conduct in-depth analysis of the existing claims systems and processes, identifying areas for
improvement and optimization.

• Previous experience in understanding and working with ICD, PCS, and CPT codes will be an
advantage.

• Translate business requirements into clear and concise technical specifications for the IT
development team.

• Responsible for on-going configuration enhancements

• Understand and analyse the insurance product with respect to benefits, coverages, limits,
exclusions etc to analyse the configuration of the product in the Product Configurator

• Create detailed documentation of business requirements, processes, and solutions.

• Develop and document business process models to illustrate current and future states

• Identify opportunities for process improvements and contribute to ongoing optimization
efforts.

• Responsible for training junior BAs &Business teamsto manage configurationsindependently

• Facilitate workshops and meetings with stakeholders to elicit and document requirements,
ensuring all relevant information is captured accurately.

• Perform detailed data analysis to identify trends, patterns, and potential areas of concern
related to claims processing and fraud detection.

• Develop andmaintain comprehensive documentation, including functional requirements, use
cases, process flows, and data mappings.

• Collaborate closely with IT teams throughout the development lifecycle to ensure proper
implementation of business requirements.

• Assist in user acceptance testing (UAT) and provide support during the testing phase to validate
that the solutions meet the business needs.

• Act as a subject matter expert (SME) on claims processing, offering insights, recommendations,
and expertise to support decision-making processes.

• Conduct demonstrations with prospects and partners to showcase the product capabilities

• Work along with the Pre Sales and Sales team in providing the accurate information and
solutions

• Provide appropriate solutions from a functional point of view depending upon the needs of
the prospects and partners

• Provide suggestions to the Product team to develop and enhance the existing product
understanding best practices and future needs

Qualifications and Skills:

• MBBS is Must.

• 5-8 years of proven experience in the area of Health insurance industry, with a strong focus
on claims processing and product configuration.

• Strong understanding of benefits, exclusions across various product lines in Health
Insurance.

• Proficiency in claims rules, fraud analytics, and data analysis techniques.

• Strong communication and interpersonal skillsto effectively collaborate with stakeholders at
all levels of the organization.

• Ability to translate complex business requirements into clear and actionable technical
specifications.

• Proven track record of successfully delivering business analysis projects in the insurance
domain.

• Ability to grasp subject quickly and come up with Solutions

• Familiarity with Agile or other project management methodologies is a plus.

• Certification in Business Analysis (e.g., CBAP) is desirable but not mandatory.