Returnship - SME-Claims HC

Job Summary

Serve as a subject matter expert in health care claims for a global organization applying deep knowledge of HIPAA claims adjudication and payer and provider processes. Collaborate with cross functional teams in a hybrid work model with night shifts to drive accurate compliant and timely claims processing that supports operational excellence and member satisfaction.

Responsibilities

• Analyze complex health care claims using detailed HIPAA and claims adjudication knowledge to ensure accurate consistent and timely outcomes that reduce rework and support operational efficiency.
• Review claims configurations benefit rules and business scenarios to validate that system adjudication logic aligns with payer and provider contract terms and organizational compliance standards.
• Collaborate with operations teams to troubleshoot adjudication defects identify root causes in claim workflows and recommend sustainable process or rule changes that reduce error rates.
• Document clear business requirements for enhancements in claims platforms by translating payer and provider needs into precise rules edits and configurations that support scalable growth.
• Perform impact assessments on proposed rule changes by analyzing historical claim patterns and projecting operational and financial implications for members providers and internal teams.
• Coordinate with quality and audit teams to design and execute test scenarios for new adjudication rules ensuring that edge cases exception handling and high volume conditions are properly addressed.
• Provide subject matter guidance to hybrid team members during night shifts by clarifying complex claim scenarios interpreting policy language and supporting consistent decision making across the operation.
• Create and maintain comprehensive process documentation reference guides and decision trees so that claims analysts can quickly resolve issues and adhere to updated standards.
• Engage with stakeholders from payer and provider domains to clarify contractual obligations reimbursement models and service expectations ensuring that claim outcomes remain transparent and defensible.
• Monitor operational dashboards and performance metrics related to claim turnaround time accuracy and adjustment rates and propose targeted improvements that enhance customer experience.
• Conduct periodic reviews of HIPAA related practices within claims processes to support privacy and security alignment in collaboration with compliance and information security partners.
• Train and mentor junior claims analysts on core adjudication concepts payer and provider workflows and best practices for documentation while promoting a culture of continuous learning.
• Participate in incident reviews and post implementation evaluations to capture lessons learned from defects system outages or policy changes and convert them into updated standard operating procedures.

Qualifications

• Apply a foundational academic background in health care business or a related field to understand payer and provider ecosystems and support data driven analysis of claims activities.
• Demonstrate three to four years of focused experience in health care claims adjudication with hands on exposure to production or configuration environments in an MNC or large enterprise setting.
• Exhibit advanced working knowledge of HIPAA guidelines as they relate to claims processing privacy and data handling and apply that knowledge consistently in day to day decisions.
• Utilize in depth understanding of payer operations including eligibility benefits and reimbursement methodologies to interpret and resolve complex claim and appeal scenarios.
• Apply practical familiarity with provider contracting concepts such as fee schedules and allowed amounts to validate that adjudication outcomes align with negotiated terms.
• Use strong analytical and problem solving skills with intermediate proficiency in spreadsheets or query tools to investigate anomalies identify trends and present clear findings.
• Communicate clearly in both written and spoken form with global stakeholders during hybrid and night shift collaboration ensuring that requirements risks and decisions are documented accurately.
• Adapt effectively to a hybrid work environment and night shift schedule while maintaining consistent productivity attention to detail and adherence to data privacy expectations.