Senior Consulting Manager, Healthcare Claims

Job Summary

A company is looking for a Senior Consulting Manager, Healthcare Claims SME.

Key Responsibilities

• Lead rule validation and optimization efforts across healthcare claims use cases
• Define and refine disposition logic for claims reviews to improve operational efficiency
• Perform false positive analysis and support UAT testing for claims analytics solutions

Required Qualifications

• 7+ years of experience in healthcare claims operations, payment integrity, or SIU functions
• Strong hands-on experience with claims adjudication platforms such as Facets, QNXT, or HealthRules
• Deep expertise in healthcare coding, including CPT, ICD 10, HCPCS
• Experience identifying and analyzing fraud, waste, and abuse patterns
• Ability to translate business and operational requirements into clear technical inputs