PC01227-HC-Web TPA-Claims Examiner-GGN

PeopleStrong; Gurugram District; On-site; INR 300,000 - 520,000; Full time

Job summary

Sharp Group seeks an Associate/Sr. Examiner (Healthcare Claims Adjudication) to join the Process Operations team in Gurgaon. You will adjudicate US healthcare claims (medical, dental, hospital) and support training for new hires, working closely with the process supervisor and client on policy updates.

The role requires a graduate degree, 0-2 years ITES/claims experience, and good knowledge of benefits, plans, and HIPAA compliance. Shift flexibility is expected.

Qualifications

• Graduate/PG with good academic background.
• 0–2 years of ITES/claims adjudication experience.
• Knowledge of contract benefits and claims processing procedures.
• Typing speed 25–30 WPM (Alpha) and 20–30 WPM numeric keys.
• Willing to work in shifts and be flexible as per business needs.

Responsibilities

• Adjudicate US Healthcare claims (Medical, Dental, Hospital, etc.).
• Conduct data entry and re-work by reviewing, researching, investigating and negotiating claims.
• Read, review and analyze claims for complete information.
• Verify benefit eligibility/membership and coverage type.
• Determine co-pay, co-insurance and deductible information per plan documents.
• Authorize payments or refer claims for further review.
• Inform supervisor about processing guideline changes to maintain accuracy.
• Possess good teamwork and train new joinees in the process.
• Focus on medical terminology during adjudication and maintain productivity and quality.

Skills

US Healthcare adjudication

Typing speed 25–30 WPM (Alpha)

Shift work readiness

Contract benefits knowledge

Communication & teamwork

Education

Graduate or Postgraduate (any stream)

Job description

Basic Details

BAND 5

Grade 10

Designation Associate

Organizational Information

Corporate Entity Sharp Group

Entity Silverskills Pvt Ltd

Business Unit Healthcare Services

Function HC- Web -TPA - Adjudication

Country India

Region North

City Gurgaon M-

Working Location Gurgaon M-

Skills

Skills

Back Office

Graduate

BA

Working Language

Job Description

Designation Examiner/Sr. Examiner

Department - Process Operations - (Adjudication )

Reports to (Designation of the RO) Team Leader

Direct Reports Not Applicable

Key working relationships Will have to closely work with the process supervisor, process trainer and client as there is an initial intense training on claims adjudication. The processing guidelines also changes with the change in policies which has to be closely monitored

Job Description ( describes primary functions of the job ) Job Summary

• 1) Adjudication of Healthcare claims (Medical, Dental, Hospital etc.)
• 2) Imparting trainings to new hires in the process
• 3) Be a part of direct conference calls with client
• 4) Participation in organisational activities

Specific Responsibilities

• 1) Will primarily be responsible for US Healthcare claims adjudication (Medical, Dental, Hospital etc.)
• 2) Conduct data entry and re-work by reviewing, researching, investigating, negotiating, processing and adjusting claims
• 3) Should read, review, and analyze claims for complete information
• 4) Should verify benefit eligibility/membership and coverage type
• 5) Determine appropriate co-pay, co-insurance and deductible information according to plan documents
• 6) Adjudicate claims appropriately after verifing the plan documents thoroughly
• 7) Authorize the appropriate payment or refer claims to investigators for further review
• 8) Should inform process supervisor about any change in processing guidelines so as to maintain accurateness of the claims payment
• 9) Should be a good team player with high on energy as s/he may be required to impart hands on training to the new joinees in the process upon gaining maturity in claims adjudication
• 10) Should have a good hold on Medical Terminologies post class room training as claims for adjudication comes with description in Medical terms
• 11) Consistently meet established productivity, schedule adherence, and quality standards
• 12) Will be required to have conference calls with the clients under supervision
• 13) Should actively participate in organisational activities (viz. ISO 27001:2013, DPA, HIPAA)

Qualification & Experience Essential Skills/ Experience & Qualification :

• 1) The candidate should be a graduate/post graduate in any stream with good academic background.
• 2) Should have 0-2 years of experience in ITES with minimum of 1 year experience in claims adjudication within a healthcare setting
• 3) Knowledge of contract benefits and claims processing procedures
• 4) Basic knowledge of computer with a typing speed of 25-30 WPM (words per minute) in Alpha keys and 20-30 WPM in numeric keys
• 5) Willing to work in shifts and should be flexible as per the business requirements

Desired Skills/Experience & Qualification:

• 1) People with prior experience in medical billing or US healthcare industry would be preferred
• 2) People from Science stream/Medical Transcription background would have an added advantage