Job Summary
This hybrid night shift role focuses on adjudicating complex health care claims while ensuring strict adherence to HIPAA regulations and alignment with payer and provider rules. The professional will handle end to end claims review resolve discrepancies and collaborate with cross functional teams to improve claims accuracy and cycle times helping the company deliver fair and timely outcomes for members and health care partners.
Responsibilities
Manage end to end claims adjudication for health care claims by applying policy guidelines payer rules and provider contracts to ensure accurate and timely payment decisions
Review complex claim scenarios with attention to medical policy benefit design and coding details to minimize financial leakage and reduce rework
Validate claims data integrity by checking member eligibility coverage limits and coordination of benefits to prevent processing errors and denials
Apply HIPAA privacy and security requirements in all claim handling activities to protect sensitive member and provider information at every step
Analyze adjudication exceptions and pended claims to identify root causes and recommend targeted process improvements that enhance operational efficiency
Collaborate with payer operations teams to clarify benefit interpretations policy updates and reimbursement models that impact claim decisions
Coordinate with provider support teams to resolve claim disputes coding queries and underpayment or overpayment issues in a professional and solution oriented manner
Document all claim decisions rationale and adjustments in the claim system with clear concise and auditable notes that support compliance and quality reviews
Use claim processing tools and reference systems to research contract terms fee schedules and medical policies ensuring consistent and compliant adjudication outcomes
Support internal quality audits and compliance checks by providing accurate case information trending insights and corrective action suggestions for recurring issues
Contribute to continuous improvement initiatives by sharing front line observations on payer and provider pain points and recommending changes that improve member and partner satisfaction
Mentor junior claim analysts by sharing best practices in claims adjudication HIPAA compliance and issue resolution while still performing individual contributor responsibilities
Align day to day work with organizational goals by prioritizing claims that impact key regulatory service levels and financial accuracy metrics that support the company mission
Qualifications
Complete a bachelors degree or equivalent formal education in health care administration business or a related discipline that supports structured analytical work in claims operations
Demonstrate at least four years of hands on experience in health care claims adjudication with direct exposure to payer and provider environments and relevant platform tools
Exhibit strong working knowledge of HIPAA regulations including privacy security and transaction standards applied consistently throughout daily claim processing
Show proven capability in interpreting payer policies provider contracts explanation of benefits and coding standards to resolve complex claim situations with minimal guidance
Display effective analytical and problem solving skills by using data and trends from high volume claims to identify patterns of denials rework or exceptions
Communicate clearly in verbal and written form with payer teams provider offices and internal stakeholders to explain claim outcomes adjustments and required next steps
Adapt comfortably to a hybrid work model and permanent night shift schedule while maintaining productivity accuracy and collaboration across locations and time zones
