Subject Matter Expert - Claims - Life & Healthcare Insurance

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.