Position Details
SME Consultant, Claims Processing Oversight
Position Overview:
Configuration risk and defect assessmentConduct comprehensive assessment of medical claims platform configuration across FEHB and PSHB lines of businessIdentify configuration risks before they manifest as defects; produce a Top-10 claims defect inventory categorized by severity, member impact, and remediation complexityReview proposed configuration changes for medical claims processing logic; provide written assessment of risk before deploymentAudit accumulator logic, benefit-build integrity, and provider-network configuration as recurring quality disciplineRoot-cause analysis disciplineDevelop recommended RCA template and discipline standards for adoption by the claims oversight functionLead root-cause analysis on member-impact incidents; produce documentation suitable for regulator scrutinyBuild pattern-detection routines that co...