Job Summary

Serve as a specialist in health care claims processing for Medicare and Medicaid claims and commercial claims within a remote work from home setting focusing on accurate adjudication compliance with health care product guidelines and timely resolution of member and provider claim inquiries during night shift operations while communicating effectively in English to support business quality and service goals.

Responsibilities

Review health care product claim submissions for Medicare and Medicaid and commercial programs to ensure accurate data capture and alignment with policy and benefit rules minimizing errors and rework to support operational efficiency and member satisfaction.
Analyze claim details and supporting documentation to validate eligibility coverage and pricing logic and to identify discrepancies or potential issues that could negatively impact members providers or company financial outcomes.




Process assigned claims queues within established service levels by applying adjudication rules and regulatory requirements ensuring that each claim outcome supports organizational quality standards and customer commitments.
Collaborate with internal operations and configuration teams through clear written and spoken English communication to resolve claim processing issues share insights on recurring defects and contribute to continuous improvement of health care product workflows.
Investigate claim escalations from customer service or provider relations by reviewing transaction history and system notes then provide detailed resolutions that address root causes and enhance trust in company claims handling.
Maintain up to date knowledge of Medicare and Medicaid regulations and commercial plan guidelines related to claims handling so that daily decisions remain compliant and reduce risk of audit findings or penalties.
Utilize claims administration systems and reporting tools to track claim status identify aging or backlog trends and propose practical

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