Job Summary

This role focuses on delivering high quality support and analysis for healthcare products within commercial claims operations in a day shift office environment. The specialist will apply domain expertise to interpret claims resolve issues and improve processing efficiency while ensuring compliance with company standards and regulatory expectations. Contributions will strengthen organizational performance and promote better outcomes across the healthcare ecosystem.

Responsibilities

Analyze commercial healthcare claims data in detail to ensure accurate adjudication and compliance with internal policies and industry regulations driving reliable claim outcomes and operational integrity.
Collaborate with cross functional teams to clarify claim requirements product rules and benefit structures helping to minimize processing errors and improve end user satisfaction.
Review complex healthcare product configurations related to commercial claims identifying gaps or inconsistencies and recommending adjustments that enhance claim accuracy and turnaround times.
Coordinate with operations and quality teams to investigate claim discrepancies document root causes and support remediation activities that reduce rework and improve service levels.
Utilize claim processing tools and internal platforms to validate eligibility coverage and pricing logic for healthcare products contributing to transparent and fair claim decisions.
Support process improvement initiatives by tracking key metrics for commercial claims proposing practical changes that improve efficiency reduce manual effort and support sustainable growth.
Communicate clearly with internal stakeholders using English read write and speak capabilities to explain claim outcomes product rules and process changes in an accessible and professional manner.
Maintain thorough documentation of claim analysis activities decisions and exceptions ensuring that records support audit readiness and consistent application of healthcare product guidelines.
Engage in knowledge sharing sessions with peers to exchange insights on commercial claims scenarios emerging product features and best practices that strengthen team capability.
Monitor day to day claim queues in the office environment prioritize work based on service commitments and ensure timely resolution of cases without requiring travel.
Apply sound judgment to escalate complex claim issues involving healthcare products enabling quick resolution by specialized teams and protecting member and client interests.
Support compliance with organizational standards by following established procedures validating data integrity and raising risks or anomalies that could impact claim reliability or regulatory adherence.
Contribute to broader organizational and societal impact by helping ensure that commercial healthcare claims are processed accurately supporting fair access to healthcare services and reinforcing trust in the healthcare system.

Qualifications

Demonstrate solid experience in healthcare products with practical exposure to product rules benefit structures and claim processing flows within commercial environments.
Possess mandatory domain experience in commercial claims with hands on involvement in evaluating claim eligibility coverage determination and payment decisions.
Bring between two and four years of professional experience in healthcare claims or related operations showing consistent performance and growing subject matter expertise.
Use strong English read write and speak skills to articulate complex claim and product information clearly to colleagues and stakeholders across business functions.
Show proficiency in using claim processing platforms and basic analytical tools to interpret data identify patterns and support continuous improvement of claims workflows.
Exhibit attention to detail and structured thinking while reviewing claims enabling accurate decisions that support company objectives and positive outcomes for members and providers.

Certifications Required

Certified Professional Coder CPC or equivalent healthcare claims certification preferred but not mandatory.

SPE-Claims HC