Job Summary

Serve as a subject matter expert in health care claims with a focus on claims adjudication and regulatory compliance in a hybrid night shift work model. Apply deep knowledge of HIPAA rules and both provider and payer operations to resolve complex claim scenarios reduce leakage and improve accuracy. Collaborate across teams to enhance claim workflows that support better outcomes for members and partners.

Responsibilities

• Review and adjudicate complex health care claims with precision to ensure accurate payment decisions that align with payer policies and contractual terms while minimizing financial leakage and rework.
• Apply expert understanding of HIPAA regulations to safeguard member data throughout claims handling activities and to support compliant documentation that can withstand internal and external audits.
• Analyze claim patterns across provider and payer data to identify root causes of denials or delays and recommend targeted process improvements that enhance turnaround time and payment accuracy.




• Collaborate with operations teams in night shift hybrid mode to resolve claim escalations in a timely manner and provide explicit guidance that enables consistent decisions across the claims portfolio.
• Document detailed adjudication rationales in claim systems so that downstream teams and external stakeholders can easily understand the basis for payment or denial decisions.
• Partner with provider relations and payer business teams to clarify advantage designs coding rules and reimbursement methodologies so that complex claim scenarios are processed correctly the first time.
• Conduct quality reviews of processed claims to verify adherence to standard operating procedures and provide structured feedback that improves team accuracy and efficiency.
• Contribute subject matter input to updates of policies and procedures related to claims adjudication HIPAA compliance and provider payer workflows to keep documentation aligned with regulatory and busin

📌 Sme Claims Hc Coimbatore
🏢 Cognizant
📍 Coimbatore