We are seeking skilled professionals for the US Healthcare Claims Adjudication – Voice Process role. The candidate will be responsible for handling inbound/outbound calls related to medical claims, ensuring accurate adjudication support, resolving provider/member queries, and maintaining compliance with US healthcare regulations.
Key Responsibilities
Handle inbound and outbound calls with providers, payers, and members regarding claims status and adjudication.
Review, analyse, and assist in adjudication of medical claims based on policy guidelines.
Explain claim denials, payment details, and EOBs (Explanation of Advantages) clearly to stakeholders.
Resolve customer queries related to advantages, eligibility, claim processing, and reimbursement.
Ensure compliance with HIPAA guidelines and US healthcare regulations.
Document interactions accurately in the system and update claim records.
Coordinate with internal teams (non-voice/back-end) for claim resolution and escalations.
Identify process gaps and suggest improvements to enhance service quality.
Meet defined quality, productivity, and SLA metrics.
Required Skills & Qualifications:
Education
Any Graduate (preferably Life Sciences, Pharmacy, Nursing, or related field)
Experience
1–5 years in US Healthcare (Claims Adjudication / Voice Process)
Prior experience in payer or provider domain