Process and adjudicate U.S. healthcare claims, calculate allowable payments manually, identify underpayments and revenue opportunities, and support data mining initiatives. Maintain productivity, quality, reporting, compliance, HIPAA adherence, and turnaround-time standards. Communicate with stakeholders, resolve claim issues, work independently, and contribute to process improvements. The role requires claims adjudication expertise, strong healthcare knowledge, accurate documentation, and reliable participation in meetings and calls.
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
EXL (NASDAQ: EXLS) is a leading data analytics and digital operations and solutions company. We partner with clients using a data and AI-led approach to reinvent business models, drive better business outcomes and unlock growth with speed. EXL harnesses the power of data, analytics, AI, and deep industry knowledge to transform operations for the world’s leading corporations in industries including insurance, healthcare, banking and financial services, media and retail, among others. EXL was founded in 1999 with the core values of innovation, collaboration, excellence, integrity and respect. We are headquartered in New York and have more than 54,000 employees spanning six continents. For more information, visit www.exlservice.com.
EXL Chennai, Tamil Nadu, IND Office
Chennai, India
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