Principal Claims Policy Expert

A company is looking for a Principal Claims & Payments Expert to serve as a lead authority on claims-related policy matters.

Key Responsibilities

Interface directly with providers on claims policies and disputes

Lead the Payment Policy Committee and provide policy recommendations

Review provider contracts for compliance and operational feasibility

Make adjudication decisions on complex claims and set policy precedents

Required Qualifications

10+ years of claims expertise in U.S. healthcare and Medicare Advantage

Extensive experience in claims policy and adjudication at a large-scale payer

Strong functional expertise in Medicare Advantage health plan operations

Expertise in medical coding (CPT, HCPCS Level II, ICD 10 CM / PCS)

Proficiency with technology and AI tools for claims and policy analysis