DesignationExaminer/Sr. Examiner
Department - ProcessOperations - (Adjudication )
Reports to (Designation of the RO)Team Leader
Direct ReportsNot Applicable
Key working relationshipsWill have to closely work with the process supervisor, process trainer and client as there is an initial intense training on claims adjudication. The processing guidelines also changes with the change in policies which has to be closely monitored
Job Description ( describes primary functions of the job )Job Summary
1) Adjudication of Healthcare claims (Medical, Dental, Hospital etc.)
2) Imparting trainings to new hires in the process
3) Be a part of direct conference calls with client
4) Participation in organisational activities
Specific Responsibilities
1) Will primarily be responsible for US Healthcare claims adjudication (Medical, Dental, Hospital etc.)
2) Conduct data entry and re-work by reviewing, researching, investigating, negotiating, processing and adjusting claims
3) Should read, review, and analyze claims for complete information
4) Should verify benefit eligibility/membership and coverage type
5) Determine appropriate co-pay, co-insurance and deductible information according to plan documents
6) Adjudicate claims appropriately after verifing the plan documents thoroughly
7) Authorize the appropriate payment or refer claims to investigators for further review
8) Should inform process supervisor about any change in processing guidelines so as to maintain accurateness of the claims payment
9)



Should be a valuable team player with high on energy as s/he may be required to impart hands on training to the new joinees in the process upon gaining maturity in claims adjudication
10) Should have a good hold on Medical Terminologies post class room training as claims for adjudication comes with description in Medical terms
11) Consistently meet established productivity, schedule adherence, and quality standards
12) Will be required to have conference calls with the clients under supervision
13) Should actively participate in organisational activities (viz. ISO 27001:2013, DPA, HIPAA)
Qualification & ExperienceEssential Skills/ Experience & Qualification:
1) The candidate should be a graduate/post graduate in any stream with good academic background.
2) Should have 2- 3 years of experience in ITES with minimum of 1 year experience in claims adjudication within a healthcare setting
3) Knowledge of contract benefits and claims processing procedures
4) Basic knowledge of computer with a typing speed of 30-40 WPM (words per minute) in Alpha keys and 20-30 WPM in numeric keys
5) Willing to work in shifts and should be flexible as per the business requirements
6) Excellent Communication Skills
Desired Skills/Experience & Qualification:
1) People with prior experience in medical billing or US healthcare industry would be preferred
2) People from Science stream/Medical Transcription background would have an added advantage

📌 -HC-Web TPA-Claims Examiner-GGN (Gurugram)
🏢 Sharp Group
📍 Gurugram