Senior Process Associate - Claims Adjudicator

Job Summary

We are looking for an experienced US Healthcare Claims Adjudication Specialist with robust 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
- Strong 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.
- Good 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.

Preferred Skills
- Experience working with multiple payers

📌 Senior Process Associate (Ambattur)
🏢 CogNet
📍 Ambattur