Job Summary
Serve as a specialist in health care claims processing for Medicare and Medicaid claims and commercial claims within a remote work from home environment focusing on accurate adjudication compliance with health care product guidelines and timely resolution of member and provider claim inquiries during night shift operations while communicating effectively in English to support business quality and service goals.
Responsibilities
Review health care product claim submissions for Medicare and Medicaid and commercial programs to ensure accurate data capture and alignment with policy and benefit rules minimizing errors and rework to support operational efficiency and member satisfaction.Analyze claim details and supporting documentation to validate eligibility coverage and pricing logic and to identify discrepancies or potential issues that could negatively impact members providers or company financial outcomes.Process assigned claims queues within established service levels by applying adjudication rules and regulatory requirements ensuring that each claim outcome supports organizational quality standards and customer commitments.Collaborate with internal operations and configuration teams through clear written and spoken English communication to resolve claim processing issues share insights on recurring defects and contribute to continuous improvement of health care product workflows.Investigate claim escalations from customer service or provider relations by reviewing transaction history and system notes then provide detailed resolutions that address root causes and enhance trust in company claims handling.Maintain up to date knowledge of Medicare and Medicaid regulations and commercial plan guidelines related to claims handling so that daily decisions remain compliant and reduce risk of audit findings or penalties.Utilize claims administration systems and reporting tools to track claim status identify aging or backlog trends and propose practical actions that help the team meet productivity and accuracy targets.Document all claim actions in the system with clear concise and complete notes to ensure transparency for downstream teams and support accurate reporting to business stakeholders.Coordinate with quality review teams when claim samples are audited by responding to findings explaining processing decisions and integrating feedback into future claim handling practices.Support night shift operations by managing workload independently escalating only complex or policy sensitive scenarios and ensuring continuous coverage that upholds service commitments in a work from home model.Contribute to knowledge sharing by updating procedure references and claim processing tips based on new health care product features or regulatory changes helping colleagues deliver consistent service and outcomes.Identify patterns in claim denials or adjustments across Medicare and Medicaid and commercial segments to recommend improvements in messaging configuration or provider education that reduce avoidable rework and member dissatisfaction.Engage in periodic training and calibration sessions to refine adjudication skills strengthen regulatory understanding and align individual performance with company objectives and societal impact through fair and accurate claims decisions.
Qualifications
Demonstrate practical experience working with health care products and claim administration platforms for at least one year and not more than three years with a proven record of accurate and timely claims processing within a structured environment.Show strong domain expertise in Medicare and Medicaid claims by confidently interpreting benefit rules cost sharing structures and regulatory requirements involved in claim adjudication and resolution activities.Apply solid knowledge of commercial claims operations including plan variations network considerations and pricing approaches so that decisions consistently reflect product intent and contractual obligations.Communicate fluently in English in both written and spoken forms to collaborate effectively with peers supervisors and cross functional teams and to craft clear claim notes and responses that support transparency and service quality.Thrive in a work from home night shift setting by maintaining focus self discipline and reliable connectivity while meeting defined productivity quality and attendance expectations without direct physical supervision.Adapt quickly to changes in health care product features claim rules and system enhancements by engaging in ongoing learning and applying updated guidance accurately to daily claim processing tasks.
Certifications Required
Preferred certification in health care claims or medical billing such as Certified Professional Coder or equivalent industry credential.
Über Cognizant
Cognizant (NASDAQ: CTSH) i ist ein Technologiedienstleister und Entwickler von KI-Lösungen. Wir schlagen die Brücke zwischen KI-Investitionen und echtem unternehmerischem Mehrwert, indem wir ganzheitliche Full-Stack-KI-Lösungen für unsere Kunden entwickeln. Mit unserer fundierten Branchen-, Prozess- und Engineering-Expertise integrieren wir die spezifischen Anforderungen von Unternehmen passgenau in Technologiesysteme. So entfalten wir das menschliche Potenzial, erzielen greifbare Ergebnisse und sichern globalen Unternehmen in einer sich rasant wandelnden Welt den entscheidenden Vorsprung. Erfahren Sie mehr unter cognizant.ai oder @cognizant.
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