Job Summary

This hybrid role for a specialist in health care claims adjudication focuses on accurate evaluation processing and resolution of payer claims within a day shift environment. The candidate will apply expertise in claims rules benefit interpretation and regulatory compliance to improve financial accuracy reduce rework and enhance member and provider experience across the companys health care operations.

Responsibilities

Review incoming health care claims thoroughly to validate member eligibility coverage details and alignment to adjudication guidelines while ensuring prompt and accurate claim outcomes that support operational efficiency and trust in company services.
Apply claims adjudication rules consistently to determine appropriate payment or denial decisions using established policies clinical edits and benefit structures to maintain financial integrity and reduce leakage across the payer portfolio.
Analyze complex claims scenarios by interpreting benefits coordination rules and policy provisions to resolve discrepancies and prevent claim backlogs thereby supporting reliable cash flows for providers and members.
Perform detailed checks for coding accuracy and claim completeness by verifying applied procedure codes diagnosis data and billing information to minimize rework and support high quality claim data for downstream analytics.
Monitor claim queues and worklists proactively to prioritize items based on aging complexity and business impact enabling timely closure of pending claims and supporting service level performance for stakeholder satisfaction.
Collaborate closely with internal operations quality and configuration teams through clear written and verbal communication to clarify benefit intents system behavior and rule application thereby avoiding recurring adjudication errors.
Investigate provider and member inquiries about claim decisions by reviewing adjudication history documentation and benefit terms to offer clear explanations that improve transparency and confidence in payer processes.
Document claim handling outcomes root cause observations and resolution steps comprehensively in designated systems to build reliable audit trails and support continuous process improvement for the organization.
Identify patterns of claim defects or systemic issues in adjudication logic by tracking recurring exceptions and reporting them to relevant teams thus contributing to enhancements that reduce manual touch and improve straight through processing.
Adhere to regulatory and compliance expectations across health care claims including privacy standards claims turnaround requirements and grievance handling to protect organization credibility and member rights.
Maintain strong focus on data accuracy and timeliness by following standardized workflows checklists and quality benchmarks which supports better analytics for cost management and care improvement initiatives.
Participate in training and knowledge sharing sessions on updates to payer policies benefit designs coding standards and system features to keep adjudication decisions aligned with evolving business and regulatory needs.
Use hybrid work model effectively by coordinating tasks and communication across onsite and remote settings ensuring seamless claims processing continuity and dependable support for team goals and customer commitments.

Qualifications

Demonstrate solid hands on experience of at least two years in health care claims adjudication applying payer rules and benefit interpretation to make accurate and consistent payment decisions.
Show practical exposure to payer domain concepts such as benefit structures coordination of benefits and provider reimbursement models enabling better understanding of claim scenarios and their financial implications.
Exhibit proficiency with claims processing systems workflow tools and standard office applications allowing efficient navigation of claim data and documentation in a hybrid working environment.
Apply foundational knowledge of medical billing concepts coding practices and industry guidelines even at a basic level to support sound adjudication decisions and reduce avoidable claim disputes.
Display strong analytical thinking and attention to detail when reviewing claim records so that data entry discrepancies missing information and configuration issues are detected and escalated appropriately.
Maintain effective communication skills to explain claim outcomes to internal stakeholders and when needed support provider facing teams thereby enhancing clarity and reducing repeated inquiries about decisions.
Manage work within structured day shift schedules while meeting productivity accuracy and turnaround expectations which supports reliable service for members and providers without the need for travel.

Certifications Required

Certified Professional Coder or equivalent health care claims certification preferred for claims adjudication specialists.

SPE-Claims HC