Cognizant Hiring - SPE / SME Claims adjudication

Dear Candidates,

We are hiring for SPE /SME Claims Adjudication role Pune location

Location: Pune
Work Model: Hybrid
Shift: Fixed Night Shift (No Rotation) |

Experience: 2+ Years Mandatory in US Healthcare Claims Adjudication using Facets Platform

Job Summary

US Healthcare Claims Adjudication Professionals with a minimum of 2+ years of hands-on claims processing/adjudication experience. The ideal candidate should possess strong knowledge of healthcare claims lifecycle, policy interpretation, benefits administration, and claims pricing methodologies. Experience working on the Facets platform is highly preferred.

Key Responsibilities

• Adjudicate medical claims accurately in accordance with client policies, benefit plans, pricing methodologies, and regulatory guidelines.
• Review claim details including member eligibility, provider information, authorization requirements, diagnosis, and procedure codes.
• Analyze and resolve claim edits, denials, pends, and exceptions within established turnaround times.
• Process professional, institutional, and ancillary claims while maintaining quality and productivity standards.
• Research and interpret benefit plans, contracts, reimbursement methodologies, and claims processing guidelines.
• Identify trends, discrepancies, and claim issues, escalating complex cases as appropriate.
• Ensure compliance with HIPAA regulations, client requirements, and organizational policies.
• Meet productivity, accuracy, and SLA targets consistently.
• Participate in quality reviews, calibration sessions, and process improvement initiatives.
• Support business continuity and operational excellence by maintaining high-quality claim adjudication standards.

Note to be mentioned that copy of this email is mandatory to attend the Interview