Job Summary
This hybrid role for a claims specialist in health care focuses on accurate processing and adjudication of medical claims within payer and provider environments while complying with HIPAA regulations and internal quality standards. The professional will work night shifts collaborate with cross functional teams and help improve claim outcomes and member experience through consistent data driven decisions.
Responsibilities
- Review health care claims with close attention to policy terms and benefit structures to ensure accurate adjudication and timely resolution for members and providers.
- Apply deep understanding of HIPAA guidelines during every claims review to protect member information and maintain strict confidentiality across all processing activities.
- Analyze complex claim scenarios involving provider and payer rules to determine eligibility coverage levels and payment responsibilities with high precision.
- Validate claim data against enrollment records provider contracts and fee schedules to identify discrepancies and correct them before payment decisions are finalized.
- Collaborate with provider support and payer operations teams to clarify missing or inconsistent information so that claims can be processed without unnecessary delays.
- Document claim decisions in clear and comprehensive narratives to support audits internal reviews and potential appeals by members or providers.
- Use claim adjudication systems and workflow tools to manage daily queues efficiently while meeting defined service levels for accuracy and timeliness.
- Identify recurring claim issues such as coding errors or contract misinterpretations and escalate patterns to supervisors so that systemic improvements can be implemented.
- Support quality assurance checks by providing feedback on claim processing rules and suggesting refinements that improve first pass resolution rates and reduce rework.
- Communicate professionally with internal stakeholders about claim outcomes explaining key drivers of payment decisions in simple and respectful language that promotes trust.
- Contribute to process optimization initiatives by sharing frontline insights on provider and payer pain points helping the company design smoother end to end claim journeys.
- Monitor operational metrics such as turnaround time accuracy rate and rework volume to stay aligned with team performance goals and company commitments to clients.
- Adhere to all night shift work schedules and hybrid work model expectations while maintaining consistent productivity and availability for collaborative discussions.
Qualifications
- Showcase proven experience working on health care claims adjudication processes with hands on exposure to benefit interpretation coverage rules and payment calculations.
- Demonstrate practical understanding of HIPAA compliance requirements in daily operations by following privacy practices secure handling of data and incident reporting norms.
- Display strong familiarity with payer business processes including eligibility verification premium and benefit management and claim payment workflows.
- Exhibit working knowledge of provider perspectives such as reimbursement expectations contract terms coding practices and clinical documentation dependencies.
- Utilize analytical and problem solving skills to interpret complex claim histories detect inconsistencies and recommend fair resolutions grounded in policy and contract rules.
- Apply solid communication and documentation abilities to create clear written notes concise emails and structured case summaries that support audits and cross team collaboration.
- Leverage adaptability and learning orientation to keep pace with evolving payer and provider policies regulatory updates and enhancements to claim processing systems.
关于高知特 (Cognizant)
高知特(Cognizant)（纳斯达克代码：CTSH）作为一家AI Builder和相关技术服务提供商，致力于通过打造全栈AI解决方案，帮助企业将人工智能投资转化为实际价值。公司凭借深厚的行业经验、流程优化和工程技术专长，将企业独特的业务场景融入科技系统，赋能组织释放人才潜能，推动切实成果，并帮助全球企业在瞬息万变的环境中保持领先。如需了解更多详情，敬请访问 cognizant.ai 或关注@cognizant。
补充雇佣信息
薪酬信息截至本职位发布之日为准。Cognizant 保留在适用法律允许的范围内随时修改该信息的权利。
申请人可能需要通过现场面试或视频会议的方式参加面试。此外，候选人在每次面试时可能需要出示其当前所在州或政府签发的有效身份证件。
Cognizant 是一家提供平等就业机会的雇主。在招聘过程中，您的申请和候选资格不会因种族、肤色、性别、宗教、信仰、性取向、性别认同、国籍、残疾、遗传信息、怀孕、退伍军人身份或任何其他受联邦、州或地方法律保护的特征而受到影响。
