Overview
Role : Subject Matter Expert (SME) – Claims ( Life & Healthcare Insurance)- InsuranceTech
Location : Mumbai / Pune ( with International Project Travelling)
Job Summary:
Role Summary :
This 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.