Claims Examiner II
Smart Data Solutions
full-time
Posted on:
Location Type: Office
Location: Perungudi • 🇮🇳 India
Visit company websiteJob Level
JuniorMid-Level
About the role
- Review, research, and adjudicate healthcare claims (professional, institutional, dental, vision) based on plan documents, contracts, and applicable regulations (e.g., CMS, HIPAA).
- Process claims using standard claim forms (CMS-1500, UB-04, ADA) and appropriate coding systems (ICD-10, CPT, HCPCS, Modifiers).
- Resolve system pends, edits, and denials through investigative research and documentation.
- Apply proper payment methodologies including fee schedules, capitation, COB, and other reimbursement rules.
- Update provider records to ensure accurate claims routing and payment.
- Process updates to member information in alignment with system rules and business requirements.
- Independently manage assigned claims to meet turnaround time and quality standards.
- Respond to inquiries or escalations, including shared email inboxes, within established SLAs.
- Accurately document actions and resolutions in claim systems, ensuring transparency and audit readiness.
- Collaborate with internal departments to resolve cross-functional claim issues.
- Maintain updated knowledge of client-specific workflows, benefit plans, policies, and procedures.
- Support process improvement activities, peer review tasks, and training efforts as needed.
- Ensure compliance with data privacy standards and internal security protocols (HIPAA, etc.).
- Participate in department meetings, calibration sessions, and continuing education.
Requirements
- High school diploma or equivalent required
- 2+ year(s) of experience in healthcare claims processing
- Experience with CMS-1500, UB-04 and ADA forms
- Familiarity with claims lifecycle workflows and COB
- Knowledge and experience with medical code sets ICD 10, HCPCS, CPT and modifiers
- Experience in repricing or demographic updates
- Strong attention to detail and accuracy
- Effective written and verbal communication
- Ability to prioritize work and meet deadlines in a high-volume environment
- Comfortable working independently and adapting to process changes
- Preferred candidates possess: 3+ year(s) of experience in health plan or TPA claims environment
- Knowledge of Medicare, Medicaid, or other government programs
- Exposure to repricing tools or claim pricing methodologies.
Benefits
- A company culture that is authentic, innovative, and collaborative!
- Our most powerful strength is our people!
- We build impactful solutions for our customers - their success is our success!
- A professional development and growth-oriented workplace
- Work-life balance with a 5-day work week and leaves as per the Labor Law of India
- A flexible environment with hybrid and remote work opportunity.
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard skills
healthcare claims processingCMS-1500UB-04ADA formsICD-10CPTHCPCSModifiersreimbursement rulesrepricing
Soft skills
attention to detailaccuracywritten communicationverbal communicationprioritizationdeadline managementindependenceadaptability
Certifications
high school diploma or equivalent