US Healthcare Claims Adjudication – Senior Process Associate
Job Title
Senior Process Associate
Experience Required
4 – 6 Years

Timing
6:30 pm - 3:30 am
Job Summary
We are looking for an experienced US Healthcare Claims Adjudication Specialist with strong knowledge in end-to-end claims processing and payer guidelines. The candidate will be responsible for adjudicating medical claims accurately while ensuring compliance with CMS, HIPAA, and client-specific policies.
Key Responsibilities
Perform end-to-end US healthcare claims adjudication.
Verify member eligibility and benefits based on Date of Service (DOS).
Apply CPT, ICD-10, HCPCS, and payer adjudication rules accurately.
Process authorization, corrected, and duplicate claims.
Handle COB (Coordination of Benefits) and multi-insurance claims processing.
Review and manage denials, appeals, and claim reprocessing activities.
Calculate deductibles, copay, coinsurance, and out-of-pocket responsibilities accurately.
Identify non-covered services, exclusions, accident claims, and policy limitations.
Ensure compliance with CMS,



HIPAA, and payer guidelines.
Maintain productivity, quality, and turnaround time as per SLA requirements.
Coordinate with internal teams and stakeholders for issue resolution and escalations.
Participate in process improvement initiatives and audits.

Required Skills
Solid knowledge of US healthcare claims adjudication process.
Good understanding of CPT, ICD-10, HCPCS, and medical terminology.
Experience in handling commercial, Medicare, and Medicaid claims.
Knowledge of denials management and appeals processing.
Familiarity with payer policies and insurance guidelines.
Strong analytical and problem-solving skills.
Positive communication and interpersonal skills.
Proficiency in MS Office and claims processing systems.
Eligibility Criteria
Any Graduate.
4 – 6 years of relevant experience in US Healthcare Claims Adjudication.
Experience in handling high-volume claims processing environments preferred.

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