Job Summary

This role supports health care claims operations by configuring and validating claim processing on Xcelys Claims Medical and QNXT Claims Medical platforms ensuring accurate adjudication for medical claims. The specialist uses strong domain knowledge in claims and medical benefits to improve cycle time reduce errors and support a high quality member and provider experience while working remotely during day shifts.

Responsibilities

Analyze health care claims on Xcelys Claims Medical and QNXT Claims Medical systems to ensure accurate benefit application and financially correct outcomes that support timely payments and customer satisfaction.
Review claim adjudication rules and configurations for medical benefits to maintain alignment with product policies regulatory requirements and operational guidelines while minimizing rework and claim reversals.
Execute end to end testing of claims adjudication scenarios in Xcelys and QNXT environments to validate pricing logic accumulators and edits before production deployment and reduce downstream defects.




Investigate claim exceptions denials and pended items by tracing benefit setup provider data and member eligibility to identify root causes and propose sustainable corrective actions.
Collaborate with business analysts and operations teams to translate claims business requirements into clear system changes for Xcelys and QNXT that enhance processing efficiency and quality.
Perform impact analysis for configuration updates on related claim flows including coordination of advantages prior authorization and referrals to prevent unintended disruptions.
Document standard operating procedures and reference guides for recurring claims scenarios so that operations teams can resolve issues consistently and accurately.
Monitor daily claims production reports to identify processing trends error patterns and aged inventories and then recommend targeted improvements for throughput and accuracy.
Support internal quality reviews

📌 SPE-Claims HC (India)
🏢 Cognizant
📍 India