SME-Claims HC

Job Summary

Serve as a subject matter expert in health care claims adjudication with a focus on payer and provider operations using advanced MS Excel skills to analyze claim data and resolve complex issues in a hybrid night shift role. Contribute to improving claims accuracy member satisfaction and cost efficiency while collaborating with cross functional teams to optimize end to end claims processes.

Responsibilities

• Analyze health care claim batches with meticulous attention to payer and provider rules to ensure accurate adjudication and timely resolution of claims while working primarily in a night shift hybrid model
• Review complex claim scenarios and apply adjudication guidelines to identify discrepancies adjust payments and minimize financial leakage for the organization and its stakeholders
• Utilize advanced MS Excel functions such as lookups and pivot based analysis to interpret large data sets spot claim processing trends and propose corrective actions that improve operational performance
• Collaborate with payer and provider operations teams to clarify benefit designs coding interpretations and contract terms to support precise claim decisions and consistent application of policies
• Document detailed claim adjudication rationales and maintain clear audit ready records that support compliance with internal standards and external regulatory expectations
• Investigate claim related issues escalated by internal teams and external partners provide clear resolutions and communicate findings that strengthen trust and transparency in claims processing
• Monitor key performance indicators related to claims turnaround times payment accuracy and rework rates and contribute insights that guide continuous improvement initiatives across the claims lifecycle
• Support implementation of process enhancements by validating rule changes testing calculation logic using structured MS Excel models and sharing structured feedback that reduces defects in production
• Provide subject matter expertise to colleagues by clarifying claim policies explaining payer and provider specific nuances and encouraging consistent application of adjudication standards in daily work
• Coordinate with quality assurance and compliance functions to identify patterns of recurring claim errors assist in root cause analysis and help design preventive controls that safeguard members and providers
• Engage with cross functional claims and operations teams to align day to day activities with the company mission of delivering fair accurate and timely claim outcomes that positively impact patient access and affordability
• Maintain up to date awareness of changes in payer guidelines and provider billing practices and translate these developments into practical adjudication updates that support organizational resilience
• Contribute to a culture of accountability and continuous learning by sharing data driven insights from claims analysis that inform strategic decisions and enhance the company contribution to the wider health care ecosystem

Qualifications

• Demonstrate strong proficiency in MS Excel including ability to manage large health care data sets and perform detailed analyses that support reliable and efficient claims adjudication
• Bring hands on experience in claims adjudication within health care operations applying payer policies and provider billing standards to ensure accurate benefit determination and payment calculation
• Possess solid knowledge of payer environments including plan structures benefit designs and reimbursement models that influence day to day decisions in claims processing work
• Possess solid understanding of provider workflows including common billing practices coding patterns and documentation requirements that affect claim submission and adjudication outcomes
• Show proven experience of two to four years in health care claims roles with consistent performance in accuracy turnaround time and adherence to documented adjudication guidelines
• Exhibit ability to work effectively in a hybrid model with night shift schedules maintaining productivity collaboration and responsiveness across both virtual and on site settings

Certifications Required

Preferred certification in health care claims or medical billing such as AAPC CPC or AHIP related claims certification

À savoir avant de postuler

• Autorisation de travail: Cognizant ne prendra en considération que les candidats à ce poste qui sont légalement autorisés à travailler au Canada sans avoir besoin d'un parrainage de l'employeur, aujourd'hui ou à l'avenir.
• Mesures d’adaptation: Si vous avez un handicap qui nécessite des mesures d’adaptation raisonnable pour effectuer une recherche d’emploi ou poser une candidature, veuillez envoyer un courriel à [email protected] avec votre demande et vos coordonnées.
• L’IA dans notre processus de recrutement: Nous utilisons des outils d'intelligence artificielle (IA) pour trier et évaluer les candidatures efficacement. Notre équipe examine ensuite les candidatures et décide qui passe à l’étape suivante.
• Poste à pourvoir: Sauf indication contraire, ce poste est actuellement vacant et nous cherchons à le pourvoir.
• Exigences linguistiques: Nous demandons à tous les candidats de posséder une connaissance de base de l’anglais afin de faciliter les communications internes. Pour les postes au Québec, la capacité à communiquer efficacement en anglais est requise car vous fournirez des services à et collaborerez avec des parties prenantes anglophones situées hors de la province.
• Inclusion: 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, des renseignements génétiques, de la grossesse, du statut d'ancien combattant ou de toute autre caractéristique protégée par les lois fédérales, provinciales ou locales.

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.