SME Consultant, Claims Processing Oversight

The Judge Group

Full-time United States, United States Business Operations Specialists

Posted:

June 19, 2026

Location:

United States, United States, United States

Job Description

SME Consultant, Claims Processing Oversight
Position Overview:Configuration risk and defect assessment
Conduct comprehensive assessment of medical claims platform configuration across FEHB and PSHB lines of business
Identify configuration risks before they manifest as defects; produce a Top-10 claims defect inventory categorized by severity, member impact, and remediation complexity
Review proposed configuration changes for medical claims processing logic; provide written assessment of risk before deployment
Audit accumulator logic, benefit-build integrity, and provider-network configuration as recurring quality discipline
Root-cause analysis discipline
Develop recommended RCA template and discipline standards for adoption by the claims oversight function
Lead root-cause analysis on member-impact incidents; produce documentation suitable for regulator scrutiny
Build pattern-detection routines that co...
                

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Job Overview

Job Type: Full-time

Location: United States, United States

Posted: June 19, 2026

Deadline: July 29, 2026