Job Summary
This hybrid role is for a claims processing professional in health care with focus on HIPAA compliance and claims adjudication for provider and payer clients in a night shift schedule. The role involves accurate review of health care claims application of benefit rules and timely resolution of discrepancies to support high quality member and provider experiences.
Responsibilities
- Review health care claims with close attention to detail to ensure accurate capture of member demographics benefit data and provider information while working in a hybrid night shift model
- Apply claims adjudication rules to determine eligibility coverage limits and cost sharing so that claims outcomes align with payer policies and contractual agreements
- Validate claims data for completeness and consistency and raise issues promptly so that incorrect information does not lead to payment errors or delays
- Interpret benefit plans and provider contracts to calculate member and payer financial responsibility and document outcomes clearly in the system of record
- Check claims against policy exclusions benefit maximums and coordination of benefits rules to minimize overpayments underpayments and rework
- Use HIPAA compliant workflows when accessing and updating member and provider information so that privacy and security requirements are consistently met
- Research claim discrepancies by referencing benefit documents historical claims and standard operating procedures to identify root causes and propose accurate resolutions
- Collaborate with internal operations quality and configuration teams through virtual channels to clarify benefits rules and ensure consistent adjudication outcomes across cases
- Respond to queries from provider and payer stakeholders by providing clear claim status updates and explanations that support trust and reduce repeat contacts
- Track individual claim queues and turnaround time targets during night shift schedules to support timely completion of work and achievement of service level commitments
- Document all claim decisions with clear rationales to enable audit readiness improve transparency and support training for future team members
- Identify recurring claim patterns such as coding mismatches or configuration gaps and escalate them for systematic fixes that enhance first pass resolution and reduce waste
- Contribute to continuous improvement activities by sharing observations from daily claim reviews that help refine processes tools and reference materials for the wider team
Qualifications
- Demonstrate working knowledge of HIPAA guidelines and privacy expectations in handling protected health information within claims processing environments
- Show foundational experience or training in claims adjudication workflows including eligibility checks benefit application and financial calculation steps
- Exhibit familiarity with payer operations including benefit structures claim payment life cycle and expectations for accuracy and turnaround time in health care settings
- Show understanding of provider perspectives including billing practices reimbursement expectations and common sources of claim inquiries or disputes
- Apply basic data entry and validation skills with strong emphasis on numeric accuracy and consistency when working with claim amounts and codes
- Use clear written and verbal communication skills to explain claim outcomes to internal stakeholders in concise and nontechnical language
- Display adaptability to hybrid work arrangements and night shift schedules while maintaining productivity and quality in a structured operations environment
Sobre a Cognizant
Cognizant (NASDAQ: CTSH) é uma construtora de IA e fornecedora de serviços de tecnologia, criando a ponte entre o investimento em IA e o valor para as empresas por meio do desenvolvimento de soluções de IA completas para nossos clientes. Nossa profunda experiência em setores, processos e engenharia nos permite incorporar o contexto único de cada organização em sistemas tecnológicos que potencializam a capacidade humana, geram resultados tangíveis e mantêm empresas globais à frente em um mundo em rápida transformação. Saiba mais em cognizant.ai ou @cognizant.
A Cognizant é uma empregadora que investe em equidade. Sua candidatura não será pautada em raça, cor, gênero, sexualidade, credo, origem, deficiência, gravidez ou qualquer outra característica protegida pelas leis brasileiras.
Informações adicionais de emprego
Os candidatos podem ser obrigados a comparecer a entrevistas presenciais ou por videoconferência. Além disso, os candidatos podem ser obrigados a apresentar seu documento de identificação emitido pelo estado ou governo atual durante cada entrevista.
Embora nosso sistema permita a candidatura em todos os idiomas, o(s) idioma(s) e o(s) nível(is) de proficiência exigidos para o trabalho variam. No entanto, é necessário um nível básico de inglês para fins de comunicação em toda a empresa.
A Cognizant é uma empregadora que investe em equidade. Sua candidatura não será pautada em raça, cor, gênero, sexualidade, credo, origem, deficiência, gravidez ou qualquer outra característica protegida pelas leis brasileiras.
Se você tem uma deficiência que requer adaptações razoáveis para procurar uma vaga de emprego ou enviar uma candidatura, envie um e-mail para [email protected] com sua solicitação e informações de contato.
