Senior Executive - Claims Audit

Claims Processing & Adjudication

• Review, analyze, and process healthcare claims accurately based on payer rules, policy guidelines, and contractual terms.
• Perform manual payment determination and allowable calculations without relying on system tools.

Revenue Optimization & Data Mining

• Identify gaps, underpayments, and missed revenue opportunities through data analysis and claims review.
• Support data mining programs by providing insights for revenue realization and process improvement.

Quality & Productivity Management

• Ensure all assigned claims inventory is completed within defined TAT while maintaining required quality standards.
• Prepare and update production, quality, and status reports regularly as per business requirements.

Communication & Coordination

• Maintain clear and professional communication with internal teams and stakeholders.
• Participate actively in meetings, calls, and discussions as required to resolve claim or process-related issues.

Compliance & Process Adherence

• Follow all compliance protocols, company policies, and HIPAA guidelines without fail.
• Ensure data confidentiality and integrity are maintained at all times.

Independence & Initiative

• Work independently with minimal supervision, demonstrating accountability and ownership for assigned tasks.
• Contribute proactively to process improvement and efficiency initiatives.

Skills and abilities

• 5+ years of experience in claims processing or claims adjudication.
• Should have a strong US healthcare knowledge.
• Should know the payment determination. Which means candidates should calculate the allowable without system support.
• Should identify the gaps for realizing higher revenue for data mining program.
• Should have a good communication with neutral accent preferred.
• Ensure assigned inventory should be completed with quality within TAT.
• Production, quality and other reports should update on timely manner as required.
• Must ensure availability for meeting/calls as required.
• Should be able to work independently with minimal guidance.
• Ensure candidates should follow compliance protocols without fail.

Qualifications

• Graduation is Mandatory
• Claims adjudication experience is Mandatory
• Prefer candidates with experience in Post adjudication/overpayment projects (Not mandatory)

Experience

• Claims Adjudication experience: Minimum 4-5 years
• Overpayment experience (Optional)

Communication

• Strong written (documentation) and oral communication skills

Working Hours

• 40 hours per week as Full time employee
• Shift time: 08:00 AM TO 05:00 PM IST (It might be changed based on project requirements)
• Weekends : Off

Telecommuter/Internet requirements, if applicable

• High Speed internet connection at home, must be broadband
• Must understand and adhere with telecommuter policy