TM-Claims HC
- Cognizant
- 8 - 9 years
- Pune
- 10 days ago
- Email to a friend
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Job Description
Job Summary
This hybrid night shift role focuses on end to end health care claims adjudication and compliance driven processing using HIPAA standards within payer and provider environments ensuring accurate decisions reduced leakages and improved member and provider experience for a global client base while contributing to high quality timely claim outcomes and sustainable business value.
Responsibilities
- Analyze complex health care claims with strong focus on HIPAA compliance and adjudication rules to deliver accurate and timely claim decisions that support client service excellence and financial integrity for payer and provider organizations.
- Apply detailed knowledge of benefits coverage policies and coordination of benefits to interpret claim data and determine appropriate payment or denial outcomes that minimize rework and prevent revenue leakage.
- Review claim edits audits and exception queues to validate rule application and propose refinements that enhance auto adjudication rates while maintaining regulatory and contractual compliance.
- Collaborate with payer operations provider relations and technical configuration teams in a hybrid model to clarify benefit designs fee schedules and contract terms that influence claim outcomes and member impact.
- Document claim decisions rationales and adjustments in clear structured formats that enable downstream analytics audit readiness and transparent communication to internal stakeholders and external partners.
- Identify recurring adjudication issues such as coding discrepancies or benefit misinterpretations and coordinate with configuration and policy teams to drive sustainable remediation and continuous improvement.
- Monitor night shift operational metrics such as turnaround time queue aging and quality scores to prioritize daily work and escalate risk items that may affect service level commitments.
- Perform root cause analysis on claim disputes rejections and appeals to recommend corrective actions that reduce future errors and enhance member and provider satisfaction.
- Coordinate closely with quality assurance and training teams to provide feedback on process gaps participate in calibration discussions and support refinement of adjudication guidelines and reference materials.
- Support knowledge sharing within the team by capturing complex adjudication scenarios edge cases and best practices that help new and existing team members resolve similar cases more efficiently.
- Engage with cross functional technical teams to validate data mappings system behaviors and integration touchpoints that influence claim intake pricing and payment processing in the end to end claims life cycle.
- Adhere to information security privacy and data handling standards in all aspects of claims work to safeguard member and provider information and to comply with organizational and regulatory requirements.
- Adapt work planning and coordination to the hybrid work model by using collaboration tools virtual meetings and clear documentation practices that support effective communication across locations and time zones.
- Manage night shift responsibilities with strong self organization and proactive communication to ensure stable coverage accurate handoffs and uninterrupted service for global client operations.
Qualifications
- Exhibit deep hands on experience in HIPAA transaction standards and privacy concepts applied to real world claim adjudication scenarios across multiple health plans and lines of business.
- Demonstrate expert level knowledge of claims adjudication processes including eligibility verification benefit determination pricing logic accumulators and post adjudication adjustments.
- Show strong domain understanding of payer operations such as benefits administration provider contracts utilization management touchpoints and claims payment workflows.
- Display sound knowledge of provider perspectives including reimbursement expectations coding and billing practices and common claim dispute drivers that influence operational efficiency.
- Utilize analytical and problem solving skills to interpret structured and unstructured claim data identify patterns and recommend process or configuration enhancements with measurable impact.
- Communicate clearly and professionally in written and spoken form to explain adjudication outcomes clarify requirements and collaborate effectively with diverse technical and business stakeholders.
- Leverage experience working in structured shift environments to maintain consistent productivity focus and quality during night shift operations while following organizational policies.
- Applied experience range of eight to nine years in health care claims and related payer or provider processes enabling independent resolution of complex cases and mentoring support for peers.
Job Classification
Industry: IT Services & ConsultingFunctional Area / Department: Customer Success, Service & OperationsRole Category: Non VoiceRole: Technical Support - Non VoiceEmployement Type: Full timeContact Details:
Company: CognizantLocation(s): Pune
Keyskills: process hipaa health claims adjudication operational efficiency root cause analysis eligibility verification regulatory requirements service excellence benefits administration concepts continuous improvement payment operations claims hippa regulations
Cognizant
Cognizant Softvision Cognizant Softvision creates impactful end-to-end digital products and solutions that result in relevant, memorable and rewarding interactions between brands and consumers. With a unique approach, we deliver sustainable innovation and business transformation for the world's...
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