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:

1. Graduation is Mandatory 
2. Claims adjudication experience is Mandatory
3. Prefer candidates with experience in Post adjudication/overpayment projects (Not mandatory)  

Experience:

1. Claims Adjudication experience: Minimum 4-5 years
2. Overpayment experience (Optional)

Communication: 

1. Strong written (documentation) and oral communication skills

Working Hours:

1. 40 hours per week as Full time employee
2. Shift time: 08:00 AM TO 05:00 PM IST (It might be changed based on project requirements)
3. Weekends : Off

Telecommuter/Internet requirements, if applicable:

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