Subject Matter Expert (Remote, Remote, US)

Location: Remote

Title: Subject Matter Expert

*Please review the Minimum Criteria before applying.

Completed applications must be received by Thursday April 23, 2026, to be considered for this position.

Minimum Criteria

You must meet the following minimum criteria (see job description for full list of requirements):

• H1, H, G grade can apply
• 2 to 5 years of healthcare claims quality auditing experience
• Experience in healthcare or related industries preferred

Role Description:

The Subject Matter Expert manages and supervises the Claims Team to ensure claims are paid properly and timely in accordance with Regulatory standards, Health Net standards, and contractual obligations, ensures that all policies & procedures are met.

Responsibilities

• Provide direction, leadership and mentoring for all their staff.
• Interacts with the client daily to resolve any issues, answer questions, and provide the production information as required.
• Provides exceptional customer service.
• Actively seeks to add value added options for the client.
• Assists the employee with the development of Individual Development Plans.
• Provides recommendations for hiring and conducts performance reviews.
• Review and analyze daily staff processing of claims, which includes reviewing quality and production reports.
• Participates in the development of operating goals and objectives for the unit; recommends, implements, and administers policies and procedures to enhance operations and production.
• Supervises and researches appeals and reprocessing of claims; reviews and resolves claims problems.
• Researches and prepares scheduled and special reports.
• Responsible to monitor and reduce expenses.
• Prepares monthly billings/invoices to be sent to the client.
• Enters appropriate personnel information into HR Office for employees within their unit/team.
• Responsible for administering any discipline that may be needed ensuring that appropriate procedures are followed.
• Attends meetings and workshops, and participates on committees, as assigned.
• Performs miscellaneous job-related duties as assigned.

Required Qualification:

• Bachelor’s degree or equivalent experience is required.
• Thorough knowledge of medical terminology, enrollment and membership activities, claim processing procedures/systems, auditing, and a thorough understanding of claim protocols and industry standards and CMS regulations as it relates to claims payment and compliance
• Knowledge and work experience with ICD9, ICD10, CPT and different coding systems (preferable)
• At least 1-3 years prior health care claims processing experience
• Supervise others by assigning/directing work; conducting employee evaluations; staff training and development; coaching and counseling
• Effective oral and written communication skills
• Ability to assess and coordinate departmental workflows effectively
• HIPAA knowledge required.
• Microsoft Office Suite Skills, especially Excel.
• Performance evaluation procedures experience desired.
• Interviewing and hiring experience preferred.
• Budgeting cost estimating, and fiscal management principles and procedures.