Senior Process Associate

Job Summary

We are looking for an experienced US Healthcare Claims Adjudication Specialist with strong knowledge in end-to-end claims processing and payer guidelines. The candidate will be responsible for adjudicating medical claims accurately while ensuring compliance with CMS, HIPAA, and client-specific policies.

Key Responsibilities

• Perform end-to-end US healthcare claims adjudication.
• Verify member eligibility and benefits based on Date of Service (DOS).
• Apply CPT, ICD-10, HCPCS, and payer adjudication rules accurately.
• Process authorization, corrected, and duplicate claims.
• Handle COB (Coordination of Benefits) and multi-insurance claims processing.
• Review and manage denials, appeals, and claim reprocessing activities.
• Calculate deductibles, copay, coinsurance, and out-of-pocket responsibilities accurately.
• Identify non-covered services, exclusions, accident claims, and policy limitations.
• Ensure compliance with CMS, HIPAA, and payer guidelines.
• Maintain productivity, quality, and turnaround time as per SLA requirements.
• Coordinate with internal teams and stakeholders for issue resolution and escalations.
• Participate in process improvement initiatives and audits.

Required Skills

• Strong knowledge of US healthcare claims adjudication process.
• Good understanding of CPT, ICD-10, HCPCS, and medical terminology.
• Experience in handling commercial, Medicare, and Medicaid claims.
• Knowledge of denials management and appeals processing.
• Familiarity with payer policies and insurance guidelines.
• Strong analytical and problem-solving skills.
• Good communication and interpersonal skills.
• Proficiency in MS Office and claims processing systems.