Job Summary

This role focuses on specialized processing and analysis of commercial health care claims ensuring accurate adjudication and compliance for complex insurance products. The candidate will apply deep expertise in health care products and commercial claims workflows to improve claim quality reduce operational risk and enhance customer outcomes in a hybrid day shift environment using English for effective communication.

Responsibilities

- Analyze end to end commercial health care claims to ensure accurate interpretation of policy benefits eligibility rules and coverage conditions driving reliable claim outcomes and minimizing financial leakage
- Review claim documentation and associated health care product information to validate data completeness and consistency enabling accurate decision making and timely resolution for stakeholders
- Coordinate with operations and product teams to clarify claim handling rules for health care products ensuring standardized application of guidelines and reducing processing errors across claim portfolios
- Investigate claim discrepancies and exceptions using structured analysis techniques identifying root causes and proposing process improvements that enhance claim accuracy and customer satisfaction
- Document claim decisions and rationales clearly in case management tools providing transparent audit trails and supporting compliance with regulatory and internal quality standards
- Collaborate with quality assurance teams to participate in claim reviews and sample assessments contributing insights that refine health care product rules and strengthen commercial claims governance




- Utilize claim processing systems and tools efficiently during day shift operations maintaining high throughput while adhering to service level expectations and accuracy benchmarks
- Engage constructively with cross functional partners through English communication to clarify complex claim scenarios reducing cycle time and improving mutual understanding of product rules
- Monitor key indicators related to commercial claims performance such as adjustment rates and rework volumes helping to identify patterns that inform training needs and product guideline updates
- Support the onboarding of new claim scenarios or product changes by interpreting business requirements into operational claim rules ensuring smooth integration into daily processing routines
- Provide explicit feedback to internal teams on recurring claim issues tied to health care products helping refine documentation standards and promote continuous improvement in claim workflows
- Maintain strict adherence to company policies and regulatory expectations for data privacy and claim handling protecting member information and reinforcing organizational trust in claims operations




- Adapt working practices to hybrid model expectations by managing tasks effectively both onsite and remote sustaining productivity and availability while delivering consistent claim outcomes

Qualifications

- Possess professional experience of two to four years in commercial claims handling within the health care domain demonstrating practical exposure to end to end claim processing life cycles
- Apply strong working knowledge of health care products including benefits structures cost sharing rules and exclusions to interpret complex claim scenarios with precision
- Demonstrate proficiency in commercial claims adjudication using claim processing platforms and standard office productivity tools to support detailed analysis and documentation activities
- Communicate fluently in English for reading writing and speaking to collaborate with colleagues document decisions and explain claim outcomes to relevant stakeholders
- Show familiarity with common regulatory and compliance expectations in health care claims such as documentation standards and audit readiness to support risk aware processing
- Utilize analytical thinking and problem solving skills to investigate claim anomalies and recommend targeted corrective actions that improve accuracy and reduce rework
- Exhibit adaptability to hybrid work arrangements and day shift schedules by organizing workload efficiently and maintaining consistent focus on quality and turnaround expectations

Certifications Required Preferred certifications include medical coding or health insurance related credentials such as CPC or AHIP health care.

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