Job Summary
Serve as a claims adjudication specialist within a global healthcare services organization applying strong expertise in MS Excel and medical claims processing for provider and payer domains. Contribute to accurate timely and compliant evaluation of healthcare claims in a hybrid work model with night shifts supporting operational excellence and better health outcomes.
Responsibilities
- Review healthcare claims for provider and payer accounts with careful attention to policy rules eligibility criteria and benefit structures to ensure accurate adjudication and reduce payment errors.
- Analyze claim data in MS Excel using filters lookups pivot tables and structured worksheets to identify discrepancies trends and patterns that support continuous improvement in claim handling.
- Validate key claim elements such as member information provider details coding consistency and billed amounts to help maintain high levels of data integrity and regulatory compliance.
- Apply adjudication guidelines and standard operating procedures consistently across all assigned claims to ensure fair processing outcomes and strengthen trust among healthcare stakeholders.
- Coordinate with internal operations and quality teams to clarify claim related questions and document resolutions that improve process efficiency and reduce repeat issues.
- Maintain detailed and well organized claim tracking logs in spreadsheet templates to monitor status turnaround times and escalations supporting transparent reporting to management.
- Respond to claim inquiries from authorized internal partners in a timely and professional manner providing clear explanations of adjudication decisions that support customer satisfaction.
- Collaborate with colleagues in the hybrid work environment to share best practices in MS Excel usage claim interpretation and payer or provider rules promoting a culture of knowledge sharing.
- Follow defined controls for night shift operations including adherence to cut off times productivity targets and quality metrics to support global service levels with minimal disruption.
- Support audit readiness by maintaining accurate digital records and standardized documentation of claim decisions enabling thorough review and continuous enhancement of control frameworks.
- Contribute to process optimization initiatives by suggesting refinements to templates checklists and validation steps helping the company improve cost effectiveness and healthcare affordability.
- Adhere to privacy and confidentiality requirements when handling sensitive member and provider information thereby protecting individual rights and reinforcing organizational integrity.
- Participate in training sessions and updates related to regulatory changes payer policies and provider contracting rules ensuring that claim adjudication remains current and compliant.
Qualifications
- Demonstrate practical experience using MS Excel for data entry validation analysis and reporting in a production environment with strong attention to accuracy and consistency.
- Exhibit hands on exposure to claims adjudication workflows in healthcare including verification coding interpretation and resolution of discrepancies for both provider and payer scenarios.
- Show understanding of provider operations such as billing practices contract terms and reimbursement models enabling precise evaluation of claims and reductions in disputes.
- Apply knowledge of payer processes including benefit structures policy provisions and denial management approaches to support correct payment decisions and lower rework volumes.
- Display strong analytical and problem solving abilities with capacity to investigate claim issues methodically and propose data based solutions that support smoother operations.
- Communicate clearly in written and verbal form with cross functional stakeholders explaining complex claim outcomes in accessible language that helps drive informed decisions.
- Adapt effectively to hybrid working arrangements and night shift schedules while maintaining high productivity and meeting defined accuracy thresholds and performance expectations.
Certifications Required
Preferred certification in medical claims processing or health insurance such as Certified Professional Coder CPC or equivalent.
Over Cognizant
Cognizant (NASDAQ: CTSH) is een bouwer van AI-oplossingen en een leverancier van technologiediensten. Wij slaan de brug tussen AI-investeringen en ondernemingswaarde door het bouwen van full-stack AI-oplossingen voor onze klanten. Onze diepgaande kennis van sectoren, processen en engineering stelt ons in staat om de unieke context van een organisatie te verankeren in technologische systemen. Deze systemen versterken het menselijk potentieel, realiseren tastbare resultaten en geven wereldwijde ondernemingen een voorsprong in een snel veranderende wereld. Ontdek hoe op cognizant.ai of @cognizant.
Aanvullende arbeidsinformatie
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