Description
Claims Processing & Adjudication:
Review, analyze, and process healthcare claims accurately based on payer rules, policy guidelines, and contractual terms.
Perform manual payment determination and allowable calculations without relying on system tools.

Revenue Optimization & Data Mining:
Identify gaps, underpayments, and missed revenue opportunities through data analysis and claims review.
Support data mining programs by providing insights for revenue realization and process improvement.

Quality & Productivity Management:
Ensure all assigned claims inventory is completed within defined TAT while maintaining required quality standards.
Prepare and update production, quality, and status reports regularly as per business requirements.

Communication & Coordination:
Maintain explicit and professional communication with internal teams and stakeholders.
Participate actively in meetings, calls, and discussions as required to resolve claim or process-related issues.

Compliance & Process Adherence:
Follow all compliance protocols, company policies,



and HIPAA guidelines without fail.
Ensure data confidentiality and integrity are maintained at all times.

Independence & Initiative:
Work independently with minimal supervision, demonstrating accountability and ownership for assigned tasks.
Contribute proactively to process improvement and efficiency initiatives.

Responsibilities
Skills and abilities:
3+ years of experience in claims processing or claims adjudication.
Should have a robust US healthcare knowledge.
Should know the payment determination. Which means candidates should calculate the allowable without system support.
Should identify the gaps for realizing higher revenue for data mining program.
Should have a positive communication with neutral accent preferred.
Ensure assigned inventory should be completed with quality within TAT.
Production, quality and other reports should update on timely manner as required.
Must ensure availability for meet

📌 Senior Executive Auditors Datamining Chennai (India)
🏢 EXL
📍 India