Job Summary
This hybrid night shift role focuses on adjudicating complex health care claims while ensuring strict adherence to HIPAA regulations and alignment with payer and provider rules. The professional will handle end to end claims review resolve discrepancies and collaborate with cross functional teams to improve claims accuracy and cycle times helping the company deliver fair and timely outcomes for members and health care partners.
Responsibilities
- Manage end to end claims adjudication for health care claims by applying policy guidelines payer rules and provider contracts to ensure accurate and timely payment decisions
- Review complex claim scenarios with attention to medical policy benefit design and coding details to minimize financial leakage and reduce rework
- Validate claims data integrity by checking member eligibility coverage limits and coordination of benefits to prevent processing errors and denials
- Apply HIPAA privacy and security requirements in all claim handling activities to protect sensitive member and provider information at every step
- Analyze adjudication exceptions and pended claims to identify root causes and recommend targeted process improvements that enhance operational efficiency
- Collaborate with payer operations teams to clarify benefit interpretations policy updates and reimbursement models that impact claim decisions
- Coordinate with provider support teams to resolve claim disputes coding queries and underpayment or overpayment issues in a professional and solution oriented manner
- Document all claim decisions rationale and adjustments in the claim system with clear concise and auditable notes that support compliance and quality reviews
- Use claim processing tools and reference systems to research contract terms fee schedules and medical policies ensuring consistent and compliant adjudication outcomes
- Support internal quality audits and compliance checks by providing accurate case information trending insights and corrective action suggestions for recurring issues
- Contribute to continuous improvement initiatives by sharing front line observations on payer and provider pain points and recommending changes that improve member and partner satisfaction
- Mentor junior claim analysts by sharing best practices in claims adjudication HIPAA compliance and issue resolution while still performing individual contributor responsibilities
- Align day to day work with organizational goals by prioritizing claims that impact key regulatory service levels and financial accuracy metrics that support the company mission
Qualifications
- Complete a bachelors degree or equivalent formal education in health care administration business or a related discipline that supports structured analytical work in claims operations
- Demonstrate at least four years of hands on experience in health care claims adjudication with direct exposure to payer and provider environments and relevant platform tools
- Exhibit strong working knowledge of HIPAA regulations including privacy security and transaction standards applied consistently throughout daily claim processing
- Show proven capability in interpreting payer policies provider contracts explanation of benefits and coding standards to resolve complex claim situations with minimal guidance
- Display effective analytical and problem solving skills by using data and trends from high volume claims to identify patterns of denials rework or exceptions
- Communicate clearly in verbal and written form with payer teams provider offices and internal stakeholders to explain claim outcomes adjustments and required next steps
- Adapt comfortably to a hybrid work model and permanent night shift schedule while maintaining productivity accuracy and collaboration across locations and time zones
À propos de Cognizant
Cognizant (NASDAQ : CTSH) est un AI Builder et une entreprise de services numériques (ESN) élaborant des solutions complètes d’IA maximisant les investissements pour des résultats concrets. Sa profonde expertise des métiers, des processus et des technologies lui permet d’intégrer dans les systèmes technologiques le contexte unique de chaque organisation de l’ingénierie à la production à l’échelle. Son objectif : améliorer l’efficacité des équipes, créer de la valeur et permettre aux grandes entreprises de rester performantes dans un monde qui évolue rapidement. Pour en savoir plus : cognizant.ai ou @cognizant.
Renseignments suppplémentaires sur l'emploi
Les informations sur la rémunération sont exactes à la date de publication. Cognizant se réserve le droit de modifier ces informations à tout moment, conformément aux lois applicables.
Les exigences linguistiques varient selon les postes, mais nous demandons à tous les candidats d’avoir une connaissance de base de l’anglais afin de faciliter les communications internes à l’échelle de l’entreprise. Pour les postes basés au Québec, une maîtrise de l’anglais est requise puisque vous fournirez des services et collaborerez avec des parties prenantes situées hors de la province, qui ne parlent pas nécessairement le français.
Cognizant est un employeur souscrivant au principe de l’égalité d’accès à l’emploi. Votre candidature et votre dossier ne seront pas examinés en fonction de la race, de la couleur, du sexe, de la religion, des croyances, de l'orientation sexuelle, de l'identité de genre, de l'origine nationale, du handicap, de l'information génétique, de la grossesse, du statut d'ancien combattant ou de toute autre caractéristique protégée telle que décrite par les lois fédérales, provinciales ou locales.
Si vous avez un handicap qui nécessite un aménagement raisonnable pour rechercher une offre d'emploi ou poser une candidature, envoyiez un courriel à [email protected] avec votre demande et vos coordonnées.
