Returnship - SME-Claims HC

Job Summary

Serve as a subject matter expert for health care claims within a hybrid global delivery model focusing on accurate adjudication and compliance with HIPAA regulations. Apply deep knowledge of payer and provider processes to resolve complex claim issues support continuous process improvement and enhance member and provider satisfaction during night shift operations.

Responsibilities

• Review complex health care claims to ensure accurate adjudication aligned with payer policies and benefit designs minimizing financial leakage and rework while operating during night shift schedule.
• Apply advanced knowledge of provider contracting terms and reimbursement methodologies to validate claim payments and identify discrepancies that impact providers and members.
• Analyze claim routing coding patterns and adjudication outcomes to detect systemic issues recommend rule updates and support improvements in auto adjudication performance.
• Coordinate with operations configuration and quality teams to clarify benefit rules resolve escalated claim cases and ensure timely closure of high priority items for payer clients.
• Interpret and implement HIPAA transaction standards for claim related data ensuring that all handled records comply with privacy and security requirements in every workflow step.
• Conduct root cause analysis on claim denials payment variances and age out backlogs then document clear action plans that drive measurable reduction in repeat issues.
• Prepare concise production reports and trend summaries that highlight service level adherence defect drivers and productivity insights for continuous process refinement.
• Guide team members on best practices in claims adjudication provider data usage and benefit interpretation by sharing reference materials and practical case examples.
• Collaborate with technology and configuration partners to validate system changes participate in user acceptance testing and confirm that new rules accurately reflect payer and provider requirements.
• Respond to internal stakeholder queries on provider and payer specific scenarios offering practical adjudication guidance that improves first time right outcomes.
• Document standard operating procedures decision matrices and reference guides for complex claim scenarios to support consistent handling across hybrid work locations.
• Support compliance reviews and internal audits by providing clear traceability of decisions audit ready documentation and timely corrections of any identified defects.
• Adapt working style to hybrid model expectations by maintaining secure handling of claim data clear communication and reliable availability during scheduled night shifts.

Qualifications

• Display strong hands on experience in health care claims adjudication with at least three years directly processing or reviewing claims for payer organizations.
• Demonstrate practical understanding of provider networks reimbursement arrangements and fee schedules that influence day to day claims determination and payment accuracy.
• Exhibit solid working knowledge of HIPAA regulations applied to claim data handling privacy safeguards and secure communication practices within operations teams.
• Show proven ability to interpret benefit plan documents and payer policies then translate them into consistent adjudication decisions for diverse claim types.
• Utilize effective analytical and spreadsheet skills to compare claim data identify anomalies and present clear findings to stakeholders in operations and quality.
• Communicate clearly in verbal and written form with cross functional teams ensuring that complex payer and provider concepts are explained in simple actionable language.
• Manage time efficiently during night shifts within a hybrid work model by prioritizing queues meeting turnaround targets and maintaining focus on quality outcomes.