Job Title: Claims Processor (Medicare Advantage US Healthcare)
Location: Remote / Night Shift
Department: US Claims Operations
Reports To: Team Lead / Manager Claims Adjudication
About Mirra Healthcare:
Mirra Health Care provides insight based, user-friendly products and services that touch all aspects of healthcare integrating the Payer, Provider, and Patient thereby enhancing quality of life of the community. We are part of an ecosystem consisting of Independent Physician Associations, Wellness and Healing centres.
Role Summary
The Claims Processor will be responsible for the end-to-end adjudication of Medicare Advantage (Part C) claims for a US-based Third-Party Administrator (TPA) or Health Plan. Working in a Global Delivery Center, you will ensure that claims are processed within CMS-mandated Turnaround Times (TAT) while maintaining high quality and financial accuracy.
Key Responsibilities
- Adjudication: Process professional (CMS-1500) and institutional (UB-04) claims for Medicare Advantage members.
- Benefit Application: Analyze US-specific Plan Benefit Packages (PBP) to determine co-pays, deductibles, and coinsurance.
- CMS Compliance: Adhere to Medicare Part C guidelines, including timely filing limits and processing accuracy.
- Workflow Management: Resolve pended claims involving Coordination of Benefits (COB) and Medicare Secondary Payer (MSP) logic.
- Data Integrity: Enter and verify data into US-based claims platforms (e.g., Facets, QNXT, Diamond, or AMISYS) with a focus on First-Pass accuracy.
- Audit Support: Collaborate with the Quality Assurance (QA) team to rectify Clean Claim errors and improve processing metrics.
Technical Skills & Qualifications
- Education: Graduate in any stream (B.Com, B.Sc, B.A.) or Pharmacy/Life Sciences background.
- US Healthcare Experience: 14 years of experience in US Healthcare (RCM/Payer side).
- Domain Knowledge: Direct experience with Medicare Advantage (MA) is mandatory. Understanding of NCD/LCD (National/Local Coverage Determinations).
- Medical Coding: Basic knowledge of ICD-10-CM, CPT-4, and HCPCS codes.
- Shift Flexibility: Must be willing to work in US Eastern/Pacific Time zones (Night shifts/Rotational shifts).
- Excel Proficiency: Ability to manage daily production logs and use basic formulas (V-Lookup, Sort/Filter).
Key Performance Indicators (KPIs)
MetricBenchmark
Production Target 80120 claims per day (depending on complexity).
Quality Score 98% or higher (Financial & Procedural Accuracy).
TAT (Turnaround Time) 100% adherence to 30-day CMS processing windows.
Attendance Strict adherence to rostered US business hours.
Metri
Required Soft Skills
- English Proficiency: Strong written and verbal communication to document claim notes clearly.
- Attention to Detail: Ability to spot small discrepancies in provider billing vs. plan authorization.
- Analytical Skills: Reasoning through Why was this claim denied based on US policy logic.
