The Claims Processing Executive will be responsible for handling US health insurance Claims from healthcare providers or their authorized representatives. The executive will assist with inquiries related to benefits, eligibility, claims, authorizations, and other support services. This position requires the ability to work across various systems, deliver exceptional customer service, and ensure compliance with privacy and regulatory standards including HIPAA and other applicable guidelines
- Handles Claims related to providers/Members: Benefits, eligibility, claim status, claims adjudication, Claims Appeal and Grievances
- Claim research and Explanation of Benefits (EOB)
- Utilize internal systems and tools (via secure access methods) to retrieve and update information.
- Document all the daily tasks related to Claims adjudicated in the system.
- Escalate unresolved cases to the appropriate internal departments.
- Adhere to all privacy laws and regulatory compliance requirements related to CMS and HIPAA.
- Meet performance targets and service level agreements (SLAs).
- High school diploma or equivalent (mandatory)
- Some college education or a completed degree (preferred)
- Strong command of the English language (verbal and written)
- Basic knowledge of Windows OS and Microsoft Office tools
- 2–5 years of Claims Adjudication (preferably in healthcare or insurance)
- Experience working in office environment with US healthcare background
- Familiarity with claims processing systems and provider portals (preferred)
- Experience in Medicare plans, especially on I-SNP will be an added advantage.
- Clear knowledge on different types of facilities in US healthcare like SNF, NF etc.,
- Excellent Communication: Ability to articulate clearly and listen actively
- Problem Solving: Uses logic and reasoning to resolve issues effectively
- Technical Proficiency: Comfortable navigating multiple systems and platforms
- Time Management: Handles tasks efficiently while meeting deadlines
- Customer Centricity: Focused on delivering a positive provider experience
- Team Collaboration: Works well with others and contributes to team success
Behavioral Attributes:
- Empathy: Understands and acknowledges provider concerns
- Professionalism: Maintains a calm and respectful tone under pressure
- Accountability: Takes ownership of responsibilities and outcomes
- Adaptability: Flexible with process changes and system updates
- Confidentiality: Complies with data privacy standards and regulations
