Job Summary
We are seeking a highly skilled and experienced Subject Matter Expert (Medico) with 7-10 years offocused experience in the health insurance industry, particularly in claims processing. Understandingthe key KPIs that drive claims processing is critical. The candidate will play a crucial role in bridging thegap between business needs and IT solutions, contributing to the enhancement of our solution. Theideal candidate will have a strong techno-functional understanding of the insurance productbenefits, coverages, claims rules, exclusions and fraud analytics and should know about ProductConfiguration in the system. Having a comprehensive grasp of Medical Codes ICD, PCS, and CPTcodes 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.
Skills: health,analytics,sme,claims,health insurance,business requirements,insurance,it,subject matter experts
