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.

Returnship - SME-Claims HC