Job Summary
This hybrid role for a claims specialist in health care focuses on accurate processing and adjudication of medical claims within payer and provider environments while complying with HIPAA regulations and internal quality standards. The professional will work night shifts collaborate with cross functional teams and help improve claim outcomes and member experience through consistent data driven decisions.
Responsibilities
- Review health care claims with close attention to policy terms and benefit structures to ensure accurate adjudication and timely resolution for members and providers.
- Apply deep understanding of HIPAA guidelines during every claims review to protect member information and maintain strict confidentiality across all processing activities.
- Analyze complex claim scenarios involving provider and payer rules to determine eligibility coverage levels and payment responsibilities with high precision.
- Validate claim data against enrollment records provider contracts and fee schedules to identify discrepancies and correct them before payment decisions are finalized.
- Collaborate with provider support and payer operations teams to clarify missing or inconsistent information so that claims can be processed without unnecessary delays.
- Document claim decisions in clear and comprehensive narratives to support audits internal reviews and potential appeals by members or providers.
- Use claim adjudication systems and workflow tools to manage daily queues efficiently while meeting defined service levels for accuracy and timeliness.
- Identify recurring claim issues such as coding errors or contract misinterpretations and escalate patterns to supervisors so that systemic improvements can be implemented.
- Support quality assurance checks by providing feedback on claim processing rules and suggesting refinements that improve first pass resolution rates and reduce rework.
- Communicate professionally with internal stakeholders about claim outcomes explaining key drivers of payment decisions in simple and respectful language that promotes trust.
- Contribute to process optimization initiatives by sharing frontline insights on provider and payer pain points helping the company design smoother end to end claim journeys.
- Monitor operational metrics such as turnaround time accuracy rate and rework volume to stay aligned with team performance goals and company commitments to clients.
- Adhere to all night shift work schedules and hybrid work model expectations while maintaining consistent productivity and availability for collaborative discussions.
Qualifications
- Showcase proven experience working on health care claims adjudication processes with hands on exposure to benefit interpretation coverage rules and payment calculations.
- Demonstrate practical understanding of HIPAA compliance requirements in daily operations by following privacy practices secure handling of data and incident reporting norms.
- Display strong familiarity with payer business processes including eligibility verification premium and benefit management and claim payment workflows.
- Exhibit working knowledge of provider perspectives such as reimbursement expectations contract terms coding practices and clinical documentation dependencies.
- Utilize analytical and problem solving skills to interpret complex claim histories detect inconsistencies and recommend fair resolutions grounded in policy and contract rules.
- Apply solid communication and documentation abilities to create clear written notes concise emails and structured case summaries that support audits and cross team collaboration.
- Leverage adaptability and learning orientation to keep pace with evolving payer and provider policies regulatory updates and enhancements to claim processing systems.
About Cognizant:
Cognizant (Nasdaq: CTSH) is an AI Builder and technology services provider, bridging the gap between AI investment and enterprise value by building full-stack AI solutions for our clients. Our deep industry, process and engineering expertise enables us to build an organization’s unique context into technology systems that amplify human potential, drive tangible outcomes and keep global enterprises ahead in a fast-changing world. See how at cognizant.ai or @cognizant.
Additional employment information
Compensation information is accurate as of the date of this posting. Cognizant reserves the right to modify this information at any time, subject to applicable law.
Applicants may be required to attend interviews in person or by video conference. In addition, candidates may be required to present their current state or government issued ID during each interview.
Cognizant is an equal opportunity employer. Your application and candidacy will not be considered based on race, color, sex, religion, creed, sexual orientation, gender identity, national origin, disability, genetic information, pregnancy, veteran status or any other characteristic protected by federal, state or local laws.
