Job Summary
Serve as a senior claims subject matter expert within a hybrid work model night shift environment applying deep knowledge of HIPAA claims adjudication and both provider and payer operations to ensure accurate compliant and timely processing of health care claims while driving continuous improvement that supports organizational goals and better health outcomes for society.
Responsibilities
- Manage complex health care claims adjudication activities to ensure accurate application of benefits provider contracts and payer policies while maintaining high productivity and quality standards in a night shift hybrid setting.
- Execute detailed claim reviews to validate eligibility member coverage coordination of benefits and pricing logic so that payments and denials are consistent with contractual and regulatory requirements.
- Apply in depth HIPAA regulations to all claims handling tasks to protect protected health information and to maintain strict compliance with privacy and security requirements.
- Utilize advanced knowledge of provider reimbursement methodologies to interpret fee schedules bundled payment rules and negotiated rate structures for both institutional and professional claims.
- Use strong payer domain expertise to interpret benefit plans coverage rules and utilization management decisions and translate them into precise claims outcomes.
- Collaborate with operations configuration and quality teams to identify adjudication defects document root causes and support fixes that enhance system accuracy and reduce rework.
- Coordinate with provider relations and customer experience teams to resolve complex claim disputes escalations and appeals in a manner that is transparent fair and compliant with internal guidelines.
- Analyze claim inventory patterns aging reports and error trends to recommend process adjustments that improve first pass resolution rates and reduce payment cycle times.
- Document adjudication scenarios decision paths and exception handling steps in clear and reusable formats that support training and knowledge sharing across peers.
- Contribute to user acceptance testing of claims platform changes by defining test scenarios executing test cases and validating results against benefit and contract rules.
- Guide peers on best practices for handling provider and payer specific scenarios such as coordination of benefits subrogation and retrospective adjustments to foster consistent claim outcomes.
- Monitor performance against operational metrics such as claim turnaround time financial accuracy and inventory levels and take corrective actions when thresholds are at risk.
- Engage constructively in continuous improvement initiatives by proposing automation rules optimization and documentation enhancements that support organizational efficiency and member satisfaction.
Qualifications
- Bring eight to nine years of hands on experience in health care claims adjudication with a strong record of working on complex claim types in a production or operations environment.
- Demonstrate expert level understanding of HIPAA administrative requirements including privacy security and transaction code set standards as applied to claims operations.
- Offer deep domain knowledge covering both provider and payer perspectives including network structures prior authorization processes and payment integrity practices.
- Display proficiency with claims adjudication systems and related workflow tools along with the ability to learn organization specific platforms rapidly.
- Show capability to interpret benefit plan documents summary of benefits materials and provider contracts and convert them into accurate rules for claim decision making.
- Exhibit strong analytical and problem solving skills that support investigation of complex claim issues using data from multiple operational and reporting sources.
- Demonstrate clear written and verbal communication skills that enable effective interaction with internal stakeholders who work across provider relations configuration compliance and customer support functions.
- Maintain a disciplined approach suited to night shift hybrid work including time management practices that sustain productivity and meet service level expectations.
- Display commitment to quality improvement by seeking feedback adopting new procedures and supporting audits or quality reviews that strengthen compliance and performance.
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。
