Job Summary

Serve as a subject matter expert in health care claims for a global organization applying deep knowledge of HIPAA claims adjudication and payer and provider processes. Collaborate with cross functional teams in a hybrid work model with night shifts to drive accurate compliant and timely claims processing that supports operational excellence and member satisfaction.

Responsibilities

Analyze complex health care claims using detailed HIPAA and claims adjudication knowledge to ensure accurate consistent and timely outcomes that reduce rework and support operational efficiency.
Review claims configurations benefit rules and business scenarios to validate that system adjudication logic aligns with payer and provider contract terms and organizational compliance standards.
Collaborate with operations teams to troubleshoot adjudication defects identify root causes in claim workflows and recommend sustainable process or rule changes that reduce error rates.




Document clear business requirements for enhancements in claims platforms by translating payer and provider needs into exact rules edits and configurations that support scalable growth.
Perform impact assessments on proposed rule changes by analyzing historical claim patterns and projecting operational and financial implications for members providers and internal teams.
Coordinate with quality and audit teams to design and execute test scenarios for new adjudication rules ensuring that edge cases exception handling and high volume conditions are properly addressed.
Provide subject matter guidance to hybrid team members during night shifts by clarifying complex claim scenarios interpreting policy language and supporting consistent decision making across the operation.
Create and maintain comprehensive process documentation reference guides and decision trees so that claims analysts can quickly resolve issues and adhere to updated standards.
Engage with stakeholders from payer and provider domains to clarify

📌 Returnship - SME-Claims HC (Pune)
🏢 Cognizant
📍 Pune