Job Summary

This hybrid role is for a claims processing professional in health care with focus on HIPAA compliance and claims adjudication for provider and payer clients in a night shift schedule. The role involves accurate review of health care claims application of benefit rules and timely resolution of discrepancies to support high quality member and provider experiences.

Responsibilities

Review health care claims with close attention to detail to ensure accurate capture of member demographics benefit data and provider information while working in a hybrid night shift model
Apply claims adjudication rules to determine eligibility coverage limits and cost sharing so that claims outcomes align with payer policies and contractual agreements
Validate claims data for completeness and consistency and raise issues promptly so that incorrect information does not lead to payment errors or delays
Interpret benefit plans and provider contracts to calculate member and payer financial responsibility and document outcomes clearly in the system of record
Check claims against policy exclusions benefit maximums and coordination of benefits rules to minimize overpayments underpayments and rework
Use HIPAA compliant workflows when accessing and updating member and provider information so that privacy and security requirements are consistently met
Research claim discrepancies by referencing benefit documents historical claims and standard operating procedures to identify root causes and propose accurate resolutions
Collaborate with internal operations quality and configuration teams through virtual channels to clarify benefits rules and ensure consistent adjudication outcomes across cases
Respond to queries from provider and payer stakeholders by providing clear claim status updates and explanations that support trust and reduce repeat contacts
Track individual claim queues and turnaround time targets during night shift schedules to support timely completion of work and achievement of service level commitments
Document all claim decisions with clear rationales to enable audit readiness improve transparency and support training for future team members
Identify recurring claim patterns such as coding mismatches or configuration gaps and escalate them for systematic fixes that enhance first pass resolution and reduce waste
Contribute to continuous improvement activities by sharing observations from daily claim reviews that help refine processes tools and reference materials for the wider team

Qualifications

Demonstrate working knowledge of HIPAA guidelines and privacy expectations in handling protected health information within claims processing environments
Show foundational experience or training in claims adjudication workflows including eligibility checks benefit application and financial calculation steps
Exhibit familiarity with payer operations including benefit structures claim payment life cycle and expectations for accuracy and turnaround time in health care settings
Show understanding of provider perspectives including billing practices reimbursement expectations and common sources of claim inquiries or disputes
Apply basic data entry and validation skills with strong emphasis on numeric accuracy and consistency when working with claim amounts and codes
Use clear written and verbal communication skills to explain claim outcomes to internal stakeholders in concise and nontechnical language
Display adaptability to hybrid work arrangements and night shift schedules while maintaining productivity and quality in a structured operations environment

PE-Claims HC