Senior Executive - Claims Audit

Claims Processing & Adjudication: Review, analyze, and process healthcare claims accurately based on payer rules, policy guidelines, and contractual terms. Perform manual payment determination and allowable calculations without relying on system tools. Revenue Optimization & Data Mining: Identify gaps, underpayments, and missed revenue opportunities through data analysis and claims review. Support data mining programs by providing insights for revenue realization and process improvement. Quality & Productivity Management: Ensure all assigned claims inventory is completed within defined TAT while maintaining required quality standards. Prepare and update production, quality, and status reports regularly as per business requirements. Communication & Coordination: Maintain clear and professional communication with internal teams and stakeholders. Participate actively in meetings, calls, and discussions as required to resolve claim or process-related issues. Compliance & Process Adherence: Follow all compliance protocols, company policies, and HIPAA guidelines without fail. Ensure data confidentiality and integrity are maintained at all times. Independence & Initiative: Work independently with minimal supervision, demonstrating accountability and ownership for assigned tasks. Contribute proactively to process improvement and efficiency initiatives. Skills and abilities: • 5+ years of experience in claims processing or claims adjudication. • Should have a strong US healthcare knowledge. • Should know the payment determination. Which means candidates should calculate the allowable without system support. • Should identify the gaps for realizing higher revenue for data mining program. • Should have a good communication with neutral accent preferred. • Ensure assigned inventory should be completed with quality within TAT. • Production, quality and other reports should update on timely manner as required. • Must ensure availability for meeting/calls as required. • Should be able to work independently with minimal guidance. • Ensure candidates should follow compliance protocols without fail. Qualifications: • Graduation is Mandatory • Claims adjudication experience is Mandatory • Prefer candidates with experience in Post adjudication/overpayment projects (Not mandatory) Experience: • Claims Adjudication experience: Minimum 4-5 years • Overpayment experience (Optional) Communication: • Strong written (documentation) and oral communication skills Working Hours: • 40 hours per week as Full time employee • Shift time: 08:00 AM TO 05:00 PM IST (It might be changed based on project requirements) • Weekends : Off Telecommuter/Internet requirements, if applicable: • High Speed internet connection at home, must be broadband • Must understand and adhere with telecommuter policy