SPE: 2+ Years of Experience in US Claims Process
SME: 5+ Years of Experience in US Claims Process

Qualification: Graduate (exclusion: BE/BTech/MCA)
For Medical Management Bachelors degree in Nursing or any health science related field.
For NA High School Equiv.

Must Have Skills: Medical Management, Claims, MRA, Medical Review, ICD
Employee Status: Full Time Employee
Shift: Rotational Shift
Travel: No
Job Location: Hyderabad, India

Job Description/Responsibility for SPE & SME:

- Process claims documents with a high degree of accuracy, ensuring zero critical errors and completion of transaction volumes within established turnaround time (TAT) and service level commitments
- Perform claims transactions including claim intake, adjudication support, payment posting, and claim rejection processing in accordance with approved Standard Operating Procedures (SOPs)
- Contribute to knowledge management initiatives by creating, updating, and maintaining process documentation, while staying current on process changes and business updates
- Review and analyze provider applications for completeness, accuracy, and compliance with established guidelines
- Verify and update provider information in client systems and databases after appropriate validation and due diligence
- Review new business applications, claim files, and medical records to identify inconsistencies, discrepancies, or eligibility concerns
- Validate potential incorrect application findings and document supporting evidence clearly, accurately, and comprehensively
- Determine the appropriate review path based on the method of application submission, including online and agent-assisted enrollments
- Request, access, review, and evaluate recorded sales calls where applicable to verify information provided during the application process
- Capture relevant call details and identify disclosures made by policyholders that may impact eligibility or claim determination
- Prepare incorrect application, discrepancy, and investigation letters using approved business templates and standards
- Apply applicable regulatory, legal, and jurisdiction-specific templates and coordinate approvals with business, compliance, and legal stakeholders
- Respond to requests for clarification, additional documentation, and case-related inquiries in a timely manner.
- Coordinate with claims processors and business teams to obtain missing information required for claim adjudication and decision-making
- Generate claim denial correspondence, update claim management systems, support policy rescission activities, and facilitate premium refund processing following approval
- Maintain strict adherence to confidentiality, compliance, privacy, and data security requirements throughout the claim review lifecycle
- Perform medical coding transactions using ICD, CPT, HCPCS,



and other applicable coding systems in accordance with client and regulatory requirements
- Analyze source documents and accurately code complex benefit plans, claim transactions, and medical records
- Conduct benefit plan analysis and prepare source documentation to support coding and adjudication activities
- Identify cases requiring medical review and assign them to the appropriate clinical or physician reviewers
- Communicate with clients and stakeholders regarding case-related issues, exceptions, and documentation requirements
- Perform quality assurance reviews on medical review assessments and ensure compliance with established quality standards
- Develop and maintain a comprehensive understanding of medical management guidelines, policies, and procedures
- Summarize key medical findings and identify relevant treatment information, clinical outcomes, causality factors, and gaps in care documentation
- Identify missing records, documentation, and information necessary to complete accurate and comprehensive medical reviews
- Adhere to Department of Labor, state, client, and organizational turnaround time and compliance requirements
- Coordinate physician reviewer referrals and proactively follow up to ensure timely completion and delivery of reviews
- Monitor and follow up on pending claims and medical reviews, initiating appropriate next steps to drive resolution
- Support management in the ongoing development, implementation, and enhancement of utilization management programs and operational initiatives
- Continuously learn and adapt to recent methods, technologies, protocols, and services required by the business
- Proactively identify and escalate operational risks, issues, and process concerns to supervisors and management
- Effectively manage assigned workload while consistently meeting productivity, quality, and service objectives
- Provide operational insights and feedback to Team Leads and Managers regarding process performance, quality trends, and team effectiveness
- Maintain confidentiality and security of client data, including Personally Identifiable Information (PII) and Protected Health Information (PHI), in accordance with client and organizational policies
- Coordinate with management regarding updates to policies, procedures, workflows, regulatory requirements, and state-specific guidelines
- Quickly learn and effectively utilize new systems, applications, and business tools as required.
- Escalate exceptions, unforeseen issues,



and situations beyond assigned authority levels to the appropriate management channels
- Participate in cross-training initiatives and support multiple processes to increase operational flexibility and business continuity
- Handle complex, high-priority, and exception transactions requiring advanced process knowledge and adherence to stringent turnaround times
- Complete missing provider information and maintain accurate provider records for both new and existing providers within client systems and database

Required Qualifications

- Experience reviewing insurance claims, underwriting information, medical records, or other regulated business documentation
- Ability to interpret complex medical and health records and evaluate findings against application responses, policy provisions, and eligibility criteria
- Strong analytical, investigative, and problem-solving skills with exceptional attention to detail.
- Excellent written documentation skills with the ability to clearly articulate findings, observations, and recommendations
- Ability to review recorded customer interactions and accurately capture relevant information and disclosures.
- Strong verbal and written communication skills with the ability to collaborate effectively with claims processors, medical reviewers, business partners, compliance teams, and legal stakeholders
- Ability to manage pending workloads, track follow-up activities, and maintain organized case documentation.
- Proficiency in claim management systems, document management tools, Microsoft Office applications, email platforms, and secure file/call review systems
- Ability to work independently while maintaining accuracy, quality, and compliance standards in a fast-paced environment

Preferred Qualifications

- Experience handling Critical Illness, Cancer, Life, Health, or Supplemental Insurance claims
- Knowledge of incorrect application investigations, contestability reviews, policy rescission processes, and eligibility reviews
- Familiarity with EIS, Genesys, voice-to-text platforms, and other claim management or call-review technologies
- Experience preparing regulated customer correspondence and collaborating with legal, regulatory, risk, or compliance teams
- Prior experience serving as a Subject Matter Expert (SME), mentor, trainer, or process escalation point
- Working knowledge of healthcare terminology, medical coding standards, and utilization management processes

Valid PAN Number - _____________________(Why PAN Required > Mandatory to Process Candidature & Find Duplicity in Internal PAN Validation Process and also to initiate a screening call.

Please reach out in case of any queries.

Sonali Chattopadhyay I Associate People Success

Orcapod Consulting Services Pvt Ltd.

Email I [email protected]

www.orcapodservices.com

(phone hidden)

📌 Claims Adjudication Requirement - SPE & SME (Hyderabad)
🏢 Orcapod Consulting Services
📍 Hyderabad