TL-Claims HC

Job Summary

Serve as a claims health care team lead in a hybrid night shift role overseeing end to end claims adjudication and compliance with HIPAA guidelines for provider and payer operations while mentoring claims analysts improving accuracy and turnaround time and supporting continuous process enhancement for clients in a global MNC environment.

Responsibilities

• Lead daily claims adjudication activities for health care clients by monitoring work queues to ensure timely and accurate processing of provider and payer claims in alignment with service level expectations and regulatory norms.
• Oversee complex claim reviews by validating eligibility coverage and benefit rules so that payment or denial decisions are consistent with contractual agreements and organizational standards.
• Provide detailed guidance to team members on applying claims business rules edits and exceptions so that manual interventions are minimized and auto adjudication outcomes are reliable.
• Review claim documentation and supporting clinical or financial records to resolve discrepancies and reduce rework by driving precise root cause identification for each issue.
• Coordinate closely with cross functional stakeholders in operations quality compliance and technology to resolve systemic claim defects and to implement sustainable process improvements.
• Monitor and analyze daily and weekly performance metrics such as accuracy turnaround time and first pass resolution to identify trends and define targeted improvement actions.
• Guide the team on correct interpretation of HIPAA requirements related to privacy security and electronic data exchange so that handling of protected health information remains fully compliant.
• Conduct periodic audits of processed claims and provide structured feedback and coaching to team members in order to uplift domain maturity and reduce error rates.
• Document operational procedures and create reference guides for complex provider and payer scenarios so that new and existing team members can execute tasks in a consistent manner.
• Collaborate with clients during calibration or governance calls to present operational performance insights gather expectations and translate them into actionable plans for the team.
• Manage scheduling and workload distribution within the night shift hybrid model so that staffing coverage aligns with volume patterns and business continuity commitments.
• Drive adoption of automation tools and workflow enhancements that improve claim processing productivity while maintaining expected quality standards and compliance posture.
• Support incident management and issue escalation by performing structured impact assessments and coordinating timely resolution updates for internal leaders and client contacts.
  
  

Qualifications

• Demonstrate solid hands on experience of at least four years in health care claims adjudication with direct accountability for processing and validating high volume provider and payer claims.
• Apply deep understanding of HIPAA regulations in day to day operations by ensuring secure handling of member and provider data and adherence to privacy and security obligations across all tasks.
• Utilize strong knowledge of provider contract terms fee schedules and coding structures to accurately determine reimbursement outcomes and to address provider inquiries with clarity.
• Leverage payer policy knowledge including benefit design coordination of benefits and medical necessity criteria to resolve complex claim scenarios and reduce appeals or resubmissions.
• Exhibit proven ability to mentor and guide junior claims analysts by providing practical on the floor support job aids and structured feedback that accelerates their learning curve.
• Communicate clearly and professionally with internal stakeholders and client representatives through email and virtual meetings to discuss claim issues share insights and align on resolutions.
• Adapt effectively to a hybrid work model and night shift operations by maintaining productivity discipline collaboration and availability within defined time windows and communication channels.