Lead I - HealthPlan

Job Description – Claims Adjudication | B1 Role: B1 – Claims Adjudication Experience: 8–10 Years Locations: Coimbatore & Trivandrum Notice Period: Immediate to 60 Days Industry: Healthcare / US Healthcare Role Summary We are looking for experienced Claims Adjudication professionals with 8–10 years of strong experience in the US Healthcare domain. The candidate will be responsible for handling complex claims, ensuring accurate adjudication, meeting operational targets, and supporting the team in delivering quality outcomes. Key Responsibilities • Review, analyze, and adjudicate healthcare claims based on payer guidelines, client requirements, and established processes. • Handle complex and high-value claims requiring detailed analysis and decision-making. • Validate member eligibility, provider details, benefits, diagnosis, procedures, and claim information. • Ensure accurate application of medical policies, benefits, coverage rules, and payment guidelines. • Identify claim discrepancies, exceptions, and potential errors and take appropriate corrective action. • Ensure claims are processed within defined quality, productivity, and SLA parameters. • Resolve complex claim-related issues and coordinate with relevant internal teams when required. • Support the team in handling escalations and process-related queries. • Conduct quality checks and provide guidance on complex claims, where required. • Identify process gaps and contribute to continuous improvement initiatives. • Ensure adherence to client processes, compliance requirements, and data privacy standards. • Support knowledge sharing and process training for team members. • Prepare and maintain process-related reports and operational updates. Required Skills • 8–10 years of experience in Claims Adjudication / Claims Processing. • Mandatory experience in the Healthcare / US Healthcare domain. • Strong understanding of the end-to-end healthcare claims lifecycle. • Good knowledge of CPT, ICD, HCPCS, medical terminology, and healthcare insurance concepts. • Strong understanding of benefits, eligibility, coverage, and claim payment rules. • Ability to independently handle complex claims and exceptions. • Strong analytical and problem-solving skills. • Excellent attention to detail and accuracy. • Good communication and stakeholder management skills. • Ability to support team members and handle process escalations. Preferred Profile • Candidates with strong experience in US Healthcare Claims Adjudication, Payer Operations, Claims Processing, or Healthcare Insurance Operations are preferred. • Prior experience handling complex claims or acting as a SME/Lead will be an added advantage. Eligibility • Experience: 8–10 Years • Notice Period: Immediate to 60 Days • Location: Coimbatore / Trivandrum • Work Mode: Work from Office