Job 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 strong 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 good 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 meeting/calls as required.
- Should be able to work independently with minimal guidance.
- Ensure candidates should follow compliance protocols without fail.

Qualifications: Qualifications:

- Graduation is Mandatory

- Claims adjudication experience is Mandatory

Prefer candidates with experience in Post adjudication/overpayment projects (Not mandatory)

- Experience:

- Claims Adjudication experience: Minimum 3 years

Overpayment experience (Optional)

- Communication:

Strong written (documentation) and oral communication skills

- Working Hours:

- 40 hours per week as Full time employee

- Shift time: 08:00 AM TO 05:00 PM IST (It might be changed based on project requirements)

Weekends : Off

- Telecommuter/Internet requirements, if applicable:

- High Speed internet connection at home, must be broadband

- Must understand and adhere with telecommuter policy

📌 Senior Executive-Auditors-Datamining (Chennai)
🏢 EXL Service
📍 Chennai