Claims Examiner II

Smart Data Solutions, a leading provider of data management, claim routing and workflow solutions to health plans and TPAs, is looking for a Claims Examiner II to join our team!

What you'll be doing

• 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.
• Flexible working in any shift.
• Adaptive to work on any project.
• Work from office is mandatory.
  
  

The duties set forth above are essential job functions for the role. Reasonable accommodations may be made to enable individuals with disabilities to perform essential job functions.

What we're looking for

Required Skills

• 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.
• Ability to maintain confidentiality and privacy.
  
  

Location: Chennai, India

Why this company is for you

Top Benefits & Perks

• 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
  
  

Who is Smart Data Solutions

Smart Data Solutions (SDS) is a technology leader in healthcare process automation and interoperability. As a strategic partner, SDS helps clients digitally transform their operations, delivering tangible value through reduced costs, streamlined workflows, and an improved customer experience. With data, AI, and automation at its core, SDS provides solutions in Digital Mailroom and Data Capture, Clearinghouse, Intelligent Medical Records, Prior Authorization and Claim Operations. Trusted by over 500 clients—including multiple Blue Cross Blue Shield plans, regional health plans, TPAs, providers, and healthcare partners—SDS streamlines complex front, middle, and back-office operations.

Smart Data Solutions is an equal opportunity employer.

All qualified applicants will receive consideration for employment without regard to race, color, sex, sexual orientation, gender identity, religion, national origin, disability, veteran status, age, marital status, pregnancy, genetic information, or other legally protected status.

4:00 PM IST to 1:00 AM IST