Job Summary

Serve as a senior claims subject matter expert within a hybrid work model night shift environment applying deep knowledge of HIPAA claims adjudication and both provider and payer operations to ensure accurate compliant and timely processing of health care claims while driving continuous improvement that supports organizational goals and better health outcomes for society.

Responsibilities

Manage complex health care claims adjudication activities to ensure accurate application of benefits provider contracts and payer policies while maintaining high productivity and quality standards in a night shift hybrid setting.
Execute detailed claim reviews to validate eligibility member coverage coordination of benefits and pricing logic so that payments and denials are consistent with contractual and regulatory requirements.
Apply in depth HIPAA regulations to all claims handling tasks to protect protected health information and to maintain strict compliance with privacy and security requirements.




Utilize advanced knowledge of provider reimbursement methodologies to interpret fee schedules bundled payment rules and negotiated rate structures for both institutional and professional claims.
Use strong payer domain expertise to interpret benefit plans coverage rules and utilization management decisions and translate them into accurate claims outcomes.
Collaborate with operations configuration and quality teams to identify adjudication defects document root causes and support fixes that enhance system accuracy and reduce rework.
Coordinate with provider relations and customer experience teams to resolve complex claim disputes escalations and appeals in a manner that is transparent fair and compliant with internal guidelines.
Analyze claim inventory patterns aging reports and error trends to recommend process adjustments that improve first pass resolution rates and reduce payment cycle times.
Document adjudication scenarios decision paths and exception handling steps

📌 Returnship - TM-Claims HC (Kochi)
🏢 Cognizant
📍 Kochi