Job Description:

Key Responsibilities:

• Handles Claims related to providers/Members: Benefits, eligibility, claim status, claims adjudication, Claims Appeal and Grievances

• Claim research and Explanation of Benefits (EOB)

• Utilize internal systems and tools (via secure access methods) to retrieve and update information.

• Document all the daily tasks related to Claims adjudicated in the system.

• Escalate unresolved cases to the appropriate internal departments.

• Adhere to all privacy laws and regulatory compliance requirements related to CMS and HIPAA.

• Meet performance targets and service level agreements (SLAs).

Required Qualifications:

• High school diploma or equivalent (mandatory)

• Some college education or a completed degree (preferred)

• Strong command of the English language (verbal and written)

• Basic knowledge of Windows OS and Microsoft Office tools

Preferred Experience:

• 2â€5 years of Claims Adjudication (preferably in healthcare or insurance)

• Experience working in office environment with US healthcare background

• Familiarity with claims processing systems and provider portals (preferred)

• Experience in Medicare plans, especially on I-SNP will be an added advantage.

• Clear knowledge on different types of facilities in US healthcare like SNF, NF etc.,

Skills and Competencies:

• Excellent Communication: Ability to articulate clearly and listen actively

• Problem Solving: Uses logic and reasoning to resolve issues effectively

• Technical Proficiency: Comfortable navigating multiple systems and platforms

• Time Management: Handles tasks efficiently while meeting deadlines

• Customer Centricity: Focused on delivering a positive provider experience

• Team Collaboration: Works well with others and contributes to team success

• Empathy: Understands and acknowledges provider concerns

• Professionalism: Maintains a calm and respectful tone under pressure

• Accountability: Takes ownership of responsibilities and outcomes

• Adaptability: Flexible with process changes and system updates

• Confidentiality: Complies with data privacy standards and regulations