Subject Matter Expert ( Sme ) - Claims ( Life & Healthcare Insurance ) @ IT Services

Job Description

Role : Subject Matter Expert (SME) Claims ( Life & Healthcare Insurance)- InsuranceTechLocation : Mumbai / Pune ( with International Project Travelling)Role SummaryThis role will focus on supporting the claims component of the platform, with strong alignment to auto-adjudication, manual workflows, and FWA detection. The SME will be involved in validating benefit configurations, defining claim processing rules, and mapping claim types and events.

Key Responsibilities :Participate in workshops with claims heads, adjudicators, and operations teams.Define and document health claims flows from pre-authorization to payment.Assist in the configuration of rules for eligibility, benefit payouts, and fraud scenarios.Validate ICD/PCS code mapping, duplicate check logic, and claim audit workflows.Provide input for STP configurations and workbench design.

Educational Qualification / Work Experience & Skills :PG / MBA / BE / B.Tech with 6+ years of experience in life/health claims operations or consulting roles.Sound knowledge of claims processing workflows and adjudication logic.Familiarity with fraud patterns, medical codes, and clinical documentation.Understanding of platform configuration and integration with policy systems.Good communication skills to work with both business and technical stakeholders.

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Keyskills:   claims processing fraud patterns clinical documentation medical codes platform configuration