Senior Claims Specialist — Complex Adjudication & Coding

Genpact; Subang Jaya; On-site; MYR 78,000 - 123,000; Full time

Job summary

Genpact is seeking a healthcare claims professional in Malaysia to support adjudication workflows. The role focuses on applying medical necessity guidelines, determining coverage, verifying eligibility, and identifying discrepancies to ensure accurate claim outcomes.

You will handle routine correspondence, route complex claims to senior specialists, and ensure adherence to operational guidelines to maintain timely processing. Genpact values diversity, inclusion, and a dynamic work environment.

Qualifications

• Responsibilities focus on claim adjudication workflows and adherence to guidelines.
• Attention to detail in medical necessity and coverage determination.

Responsibilities

• Analyzes and approves claim that cannot be auto adjudicated
• Apply medical necessity guidelines, determine coverage, complete eligibility verification, identify discrepancies
• Apply all cost containment measures to assists in the claim adjudications process
• Coordinates responses for routine written correspondence related to claim processing issues
• Routes and escape complex claims to Senior Claim Benefits Specialist
• Proofs claim or referral submission to determine, review, or apply appropriate guidelines, coding, member identification
• Processes provider selection processes, claim coding, including procedure, diagnosis and pre-coding requirements
• In accordance with prescribed operational guidelines, manages claims on desk, route/queues, and system within specified turn-around-time parameters
• Utilizes all applicable system functions available ensuring accurate and timely claim processing service (i.e., utilizes Claim Check, reasonable and customary data, and other post-containment tools).

Job description

Genpact is seeking a healthcare claims professional in Malaysia to support adjudication workflows. The role focuses on applying medical necessity guidelines, determining coverage, verifying eligibility, and identifying discrepancies to ensure accurate claim outcomes.

You will handle routine correspondence, route complex claims to senior specialists, and ensure adherence to operational guidelines to maintain timely processing. Genpact values diversity, inclusion, and a dynamic work environment.