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.
コグニザントについて
コグニザント（NASDAQ: CTSH）は、AI Builderおよびテクノロジーサービスプロバイダーとして、お客様にフルスタックのAIソリューションを構築することで、AI投資と企業価値を結ぶ架け橋となっています。業界、ビジネスプロセス、エンジニアリングに関する当社の深い専門知識を活かし、組織固有のビジネス環境をテクノロジー・システムに組み込みます。これにより、人間の可能性を最大限に引き出し、確かな成果を実現するとともに、急速に変化する世界においてグローバル企業が常に一歩先を行くための支援を行っています。 詳細については、cognizant.ai をご覧ください。
雇用に関する追加情報
本募集に記載されている報酬情報は、掲載日時点で正確なものです。Cognizantは、適用される法令に従い、いつでも本情報を変更する権利を留保します。
応募者は、対面またはビデオ会議による面接への参加を求められる場合があります。また、各面接の際に、現在有効な州政府または政府発行の身分証明書の提示を求められる場合があります。
Cognizantは機会均等雇用主です。応募および選考において、人種、肌の色、性別、宗教、信条、性的指向、性自認、国籍、障がい、遺伝情報、妊娠、退役軍人の地位、その他連邦法・州法・地方自治体の法律により保護されるいかなる特性に基づく差別も行いません。
