Senior Executive - Claims Audit

• Description
• 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.

• Responsibilities
• 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
• 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