SME Consultant, Claims Processing Oversight
The Judge Group
Remote
Posted on May 7, 2026
SME Consultant, Claims Processing Oversight
Position Overview:
Location: Remote-first; quarterly travel to Lee's Summit, MO
Time commitment ~160 hours per month, full engagement basis
Target start: Within 30 days of contract execution
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 connect individual incidents to systemic configuration risks
- Recommend escalation thresholds for member-impact incidents
- Advisory support
- Provide written and verbal advisory input to the Interim COO on claims operational matters, vendor configuration changes, and remediation priorities
- Coordinate informally with the claims oversight team on findings, methodology, and prioritization
- Support the Interim COO in claims-specific vendor governance preparation; do not face the vendor directly in the first 30 days of engagement
- Monthly Monthly progress report to the Interim COO summarizing observations, recommendations, and recommended next-period focus
- 25+ years of payer claims operations leadership
- Direct experience with major claims platforms — Facets, HealthRules, QNXT, NASCO, or proprietary platforms at production scale
- Demonstrated RCA capability — has personally led root-cause analysis on claims defects that became regulator-facing issues
- Track record of configuration root-cause work that has survived external audit
- Federal program claims operations experience — FEHB, PSHB, Medicare Advantage, Medicaid, or Tricare
- Available for engagement within 4–6 weeks of contract execution
- Former VP or SVP Claims Operations at a national or large-regional payer
- Direct experience with accumulator-related configuration scenarios and remediation
- Direct UMR, UnitedHealth, or comparable major TPA exposure
- Experience producing claims oversight reports for regulator submission (OPM, CMS, state DOI)
- Engagement governance and acceptance criteria
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