Job Summary

Serve as a senior claims subject matter expert within a hybrid work model night shift environment applying deep knowledge of HIPAA claims adjudication and both provider and payer operations to ensure accurate compliant and timely processing of health care claims while driving continuous improvement that supports organizational goals and better health outcomes for society.

Responsibilities

Manage complex health care claims adjudication activities to ensure accurate application of benefits provider contracts and payer policies while maintaining high productivity and quality standards in a night shift hybrid setting.
Execute detailed claim reviews to validate eligibility member coverage coordination of benefits and pricing logic so that payments and denials are consistent with contractual and regulatory requirements.
Apply in depth HIPAA regulations to all claims handling tasks to protect protected health information and to maintain strict compliance with privacy and security requirements.
Utilize advanced knowledge of provider reimbursement methodologies to interpret fee schedules bundled payment rules and negotiated rate structures for both institutional and professional claims.
Use strong payer domain expertise to interpret benefit plans coverage rules and utilization management decisions and translate them into precise claims outcomes.
Collaborate with operations configuration and quality teams to identify adjudication defects document root causes and support fixes that enhance system accuracy and reduce rework.
Coordinate with provider relations and customer experience teams to resolve complex claim disputes escalations and appeals in a manner that is transparent fair and compliant with internal guidelines.
Analyze claim inventory patterns aging reports and error trends to recommend process adjustments that improve first pass resolution rates and reduce payment cycle times.
Document adjudication scenarios decision paths and exception handling steps in clear and reusable formats that support training and knowledge sharing across peers.
Contribute to user acceptance testing of claims platform changes by defining test scenarios executing test cases and validating results against benefit and contract rules.
Guide peers on best practices for handling provider and payer specific scenarios such as coordination of benefits subrogation and retrospective adjustments to foster consistent claim outcomes.
Monitor performance against operational metrics such as claim turnaround time financial accuracy and inventory levels and take corrective actions when thresholds are at risk.
Engage constructively in continuous improvement initiatives by proposing automation rules optimization and documentation enhancements that support organizational efficiency and member satisfaction.

Qualifications

Bring eight to nine years of hands on experience in health care claims adjudication with a strong record of working on complex claim types in a production or operations environment.
Demonstrate expert level understanding of HIPAA administrative requirements including privacy security and transaction code set standards as applied to claims operations.
Offer deep domain knowledge covering both provider and payer perspectives including network structures prior authorization processes and payment integrity practices.
Display proficiency with claims adjudication systems and related workflow tools along with the ability to learn organization specific platforms rapidly.
Show capability to interpret benefit plan documents summary of benefits materials and provider contracts and convert them into accurate rules for claim decision making.
Exhibit strong analytical and problem solving skills that support investigation of complex claim issues using data from multiple operational and reporting sources.
Demonstrate clear written and verbal communication skills that enable effective interaction with internal stakeholders who work across provider relations configuration compliance and customer support functions.
Maintain a disciplined approach suited to night shift hybrid work including time management practices that sustain productivity and meet service level expectations.
Display commitment to quality improvement by seeking feedback adopting new procedures and supporting audits or quality reviews that strengthen compliance and performance.

Returnship - TM-Claims HC