Claims Configuration SME

Claims Configuration Subject-Matter Expert (SME) Consultant

Location:

Hybrid On-site on an alternating-week basis (every other week) in Lees Summit, MO

Time commitment ~160 hours per month, full engagement basis

Target start:
Within 30 days of contract execution

We are seeking a Senior Claims Configuration Subject Matter Expert (SME) to serve as an independent expert within a large-scale operational stabilization effort following a third‑party administrator (TPA) transition. In this role, you will diagnose and remediate systemic claims‑adjudication and benefit‑configuration defects across medical lines of business, quantify member and financial impact, and strengthen accountability between the health plan and its TPA.

This is a hands‑on diagnostic and advisory role requiring exceptional claims‑analysis skills — including the ability to interpret adjudication logic at the configuration level, independently isolate root cause, and critically evaluate analyses produced by internal teams and the TPA.

• Conduct root‑cause analysis of claims‑adjudication and benefit‑configuration defects across institutional and professional medical claims; produce clear, defensible documentation outlining root cause, impacted periods, claim volumes, and financial exposure.
• Validate brochure‑to‑system configuration by interpreting plan benefit language and confirming alignment with adjudication outcomes; identify and document configuration gaps.
• Resolve Coordination of Benefits (COB) and Medicare scenarios
  , including MSP rules, Part A/B coordination, secondary‑payer logic, per‑diem and bundling rules, accumulator behavior, and OBRA requirements.
• Analyze institutional claim processing
  , including bill‑type routing, SNF inpatient vs. unbundled therapy, room‑and‑board vs. therapy reimbursement, and maternity/newborn benefit configuration.
• Quantify member and financial impact
  , including claim counts, time periods affected, and over/underpayment exposure to support remediation prioritization and regulatory reporting.
• Critically evaluate TPA‑produced analyses
  , challenging sampling methodology, suspect‑rate logic, and impact estimates when unsupported by evidence.
• Maintain structured, audit‑ready issue documentation suitable for executive governance and regulatory review.
• Partner across plan and TPA teams
  , operating within a joint governance framework to strengthen oversight, vendor accountability, and internal capability.

• Exceptional claims‑analysis expertise with a proven ability to dissect complex adjudication behavior, isolate configuration‑level root cause, and quantify impact with rigor.
• Demonstrated analytical independence and skepticism
  , with the ability to challenge third‑party methodologies and conclusions.
• 10+ years of experience in health plan claims operations and configuration, including hands‑on benefit and adjudication system setup.
• Expert‑level knowledge of COB and Medicare coordination
  , including MSP rules and Part A/B processing.
• Hands‑on experience with institutional and professional claim types, bill types/revenue codes, preventive‑services adjudication, maternity/newborn benefits, and authorization/visit‑limit logic.
• Experience managing payer–TPA relationships
  , including enforcing configuration standards and performance expectations.
• Strong written communication skills
  , with the ability to produce precise, regulator‑ready documentation.