Job Summary
This role focuses on specialized processing and analysis of commercial health care claims ensuring accurate adjudication and compliance for complex insurance products. The candidate will apply deep expertise in health care products and commercial claims workflows to improve claim quality reduce operational risk and enhance customer outcomes in a hybrid day shift environment using English for effective communication.
Responsibilities
Analyze end to end commercial health care claims to ensure accurate interpretation of policy benefits eligibility rules and coverage conditions driving reliable claim outcomes and minimizing financial leakageReview claim documentation and associated health care product information to validate data completeness and consistency enabling accurate decision making and timely resolution for stakeholdersCoordinate with operations and product teams to clarify claim handling rules for health care products ensuring standardized application of guidelines and reducing processing errors across claim portfoliosInvestigate claim discrepancies and exceptions using structured analysis techniques identifying root causes and proposing process improvements that enhance claim accuracy and customer satisfactionDocument claim decisions and rationales clearly in case management tools providing transparent audit trails and supporting compliance with regulatory and internal quality standardsCollaborate with quality assurance teams to participate in claim reviews and sample assessments contributing insights that refine health care product rules and strengthen commercial claims governanceUtilize claim processing systems and tools efficiently during day shift operations maintaining high throughput while adhering to service level expectations and accuracy benchmarksEngage constructively with cross functional partners through English communication to clarify complex claim scenarios reducing cycle time and improving mutual understanding of product rulesMonitor key indicators related to commercial claims performance such as adjustment rates and rework volumes helping to identify patterns that inform training needs and product guideline updatesSupport the onboarding of new claim scenarios or product changes by interpreting business requirements into operational claim rules ensuring smooth integration into daily processing routinesProvide clear feedback to internal teams on recurring claim issues tied to health care products helping refine documentation standards and promote continuous improvement in claim workflowsMaintain strict adherence to company policies and regulatory expectations for data privacy and claim handling protecting member information and reinforcing organizational trust in claims operationsAdapt working practices to hybrid model expectations by managing tasks effectively both onsite and remote sustaining productivity and availability while delivering consistent claim outcomes
Qualifications
Possess professional experience of two to four years in commercial claims handling within the health care domain demonstrating practical exposure to end to end claim processing life cyclesApply strong working knowledge of health care products including benefits structures cost sharing rules and exclusions to interpret complex claim scenarios with precisionDemonstrate proficiency in commercial claims adjudication using claim processing platforms and standard office productivity tools to support detailed analysis and documentation activitiesCommunicate fluently in English for reading writing and speaking to collaborate with colleagues document decisions and explain claim outcomes to relevant stakeholdersShow familiarity with common regulatory and compliance expectations in health care claims such as documentation standards and audit readiness to support risk aware processingUtilize analytical thinking and problem solving skills to investigate claim anomalies and recommend targeted corrective actions that improve accuracy and reduce reworkExhibit adaptability to hybrid work arrangements and day shift schedules by organizing workload efficiently and maintaining consistent focus on quality and turnaround expectations
Certifications Required
Preferred certifications include medical coding or health insurance related credentials such as CPC or AHIP health care.
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.
