18 Adjudication Jobs

As a Claims Processing & Adjudication professional, you will be responsible for evaluating and processing medical/health insurance claims in accordance with policy terms, SOPs, and quality benchmarks. Your role will involve validating coverage, exclusions, sub-limits, and waiting periods against policy documents to ensure accurate claim processing. Ensuring documentation accuracy and compliance is crucial in this role. You will be required to maintain complete and compliant claim files that adhere to IRDAI guidelines and internal policies. Participation in quality control reviews and corrective actions will be necessary to uphold production and quality standards. Additionally, preparing detailed claim notes, summaries, and system entries with zero data discrepancies will be part of your routine tasks. Effective customer communication is key in this position. Handling inbound/outbound calls and emails to explain policy terms and conditions, claim decisions, and necessary documents to customers is essential. Providing timely status updates and resolving customer queries in a professional manner will be a significant aspect of your daily responsibilities. You will also be responsible for fraud detection and investigation. Identifying suspicious patterns, inconsistencies, or potential fraud and escalating for further investigation when necessary will be part of your duties. Conducting basic fact-finding activities such as doctor/hospital verification and requesting additional documents to support validity checks will also be required. In the realm of issue resolution and coordination, you will play a vital role in liaising with hospitals, TPAs, and internal teams to resolve mismatches, billing errors, and document gaps efficiently. Adaptability and continuous improvement are essential in this role. You will need to be able to work across multiple product lines and processes, supporting your peers during peak workloads. Additionally, suggesting process improvements to enhance turnaround time, accuracy, and customer experience will be encouraged. Participation in refresher trainings and staying updated on regulatory changes will also be expected. Keeping track of daily productivity, pending queues, and exceptions, and reporting them to the team lead/manager will be part of your responsibilities. Maintaining secure records and ensuring the confidentiality of customer data at all times is of utmost importance. If you are looking to embark on a full-time career in the field of Claims Processing & Adjudication and are eager to contribute to a dynamic team, we encourage you to apply now at btwgroup.co/careers. Job Types: Full-time, Fresher Work Location: In person For further inquiries, please contact the employer at +91 9503776369.,

Job Summary Join our dynamic team as a PE-Claims HC specialist where you will play a crucial role in processing and adjudicating claims with precision and efficiency. This hybrid role requires a keen understanding of Medicare and Medicaid claims ensuring compliance and accuracy. With a focus on night shifts you will contribute to our mission of delivering exceptional healthcare solutions without the need for travel. Responsibilities Process claims with a high degree of accuracy ensuring compliance with Medicare and Medicaid regulations. Analyze claims data to identify discrepancies and resolve issues promptly. Collaborate with team members to streamline claims adjudication processes. Maintain up-to-date knowledge of industry standards and regulatory changes. Utilize technical skills to enhance claims processing efficiency. Communicate effectively with stakeholders to ensure clarity and understanding of claims processes. Implement best practices to improve overall claims management. Monitor claims processing metrics to ensure timely and accurate adjudication. Provide feedback and suggestions for process improvements. Support the team in achieving departmental goals and objectives. Ensure all claims are processed within established timelines. Assist in the development of training materials for new team members. Contribute to a positive work environment by fostering collaboration and teamwork. Qualifications Possess strong analytical skills to assess and adjudicate claims accurately. Demonstrate proficiency in claims adjudication processes and tools. Exhibit a solid understanding of Medicare and Medicaid claims requirements. Show excellent communication skills to interact with various stakeholders. Have the ability to work effectively in a hybrid work model. Display a keen attention to detail to ensure compliance and accuracy. Certifications Required N / A

About Us: Medi Assist is India's leading Health Tech and Insure Tech company focused on administering health benefits across employers, retail members, and public health schemes. We consistently strive to drive innovation and participate in such initiatives, to lower health care costs. Our Health Benefits: Administration model is designed to deliver the tools necessary for a health plan to succeed, whether its our modular claims management system, our technology that unveils data to make important decisions, or our service solutions built around the voice of the customer. In short, our goal is to link our success to that of our members Roles and Responsibilities: Check the medical admissibility of a claim by confirming the diagnosis and treatment details. Scrutinize the claims, as per the terms and conditions of the insurance policy. Interpret the ICD coding, evaluate co-pay details, classify non-medical expenses, room tariff, capping details, differentiation of open billing and package etc. Understand the process difference between PA and an RI claim and verify the necessary details accordingly. Verify the required documents for processing claims and raise an IR in case of an insufficiency. Coordinate with the LCM team in case of higher billing and with the provider team in case of non-availability of tariff. Approve or deny the claims as per the terms and conditions within the TAT. Handle escalations and responding to mails accordingly. Work From Office only Interested candidates can share their CVs to Dona- 9632777628

We are hiring!! HR Recruiter: Arun Kumar Industry: ITES/BPO Category: International Non-Voice Division: Healthcare International Business We are looking for enthusiastic candidates with excellent communication to join our team as Customer Support Associates in the International Non-Voice Process for Healthcare. Job Title: CSA and Senior CSA Grade: H1/H2 Function/Department: Operations Reporting to: Team Lead Role Description: Roles & Responsibilities (Indicative not exhaustive) A claims examiner needs to analyse multiple documents / contracts and decide to pay / deny the claim submitted by member or providers with respect to client specifications. The claims examiner should also route the claim to different department or provider / member for any missing information that required for claims adjudication. The claims needs to be completed adhering to required TAT and quality SLA. Key Results Production, Quality Shift and Schedule adherence Process Knowledge Minimum Eligibility: Candidates should have minimum 1 year Experience in Claims Adjudication & Claims Adjustment or Claims Adjudication with Appeals & Grievances Shift Details: Night shift / Flexible to work in any shift and timingCab Boundary Limit: Up to 30 km (One way drop cab) Job Location: Firstsource Solution Limited,5th floor ETA Techno Park, Block 4, 33 OMR Navallur, Chennai, Tamil Nadu 603103.Landmark near Vivira Mall. Contact: Arun HR Phone: 6374232238 Email: arun.kumar9@firstsource.com If you are interested please share your updated CV to the arun.kumar9@firstsource.com or 6374232238 Join us to be part of a dynamic team with career growth opportunities. We look forward to seeing you at the interview! You can refer your friends as well! Disclaimer: Firstsource follows a fair, transparent, and merit-based hiring process. We never ask for money at any stage. Beware of fraudulent offers and always verify through our official channels or arun.kumar9@firstsource.com

POSITION: MEDICAL OFFICER PA/RI APPROVER PURPOSE OF ROLE: To scrutinize and process the claims within the agreed TAT by having an understanding of the policy terms & conditions while applying their domain medical knowledge. Designation Function Medical Officer/Consultant Claims PA/RI Approver Reporting to Location Assistant Manager Claims Mumbai/Bangalore Educational Qualification Shift BHMS, , BAMS, MBBS(Indian registration Required) Rotational Shift (for female employee shift ends at 8:30 PM) 6 rotational week offs Provided per month Week offs Related courses attended None Management Level Junior Management Level Industry Type Hospital/TPA/Healthcare/Insurance Roles and Check the medical admissibility of a claim by confirming the diagnosis and treatment details. Scrutinize the claims, as per the terms and conditions of the insurance policy Interpret the ICD coding, evaluate co-pay details, classify non-medical expenses, room tariff, capping details, differentiation of open billing and package etc. • • • Responsibilities Understand the process difference between PA and an RI claim and verify the necessary details accordingly. • Verify the required documents for processing claims and raise an IR in case of an insufficiency. Coordinate with the LCM team in case of higher billing and with the provider team in case of non- availability of tariff. • • Approve or deny the claims as per the terms and conditions within the TAT. • Handle escalations and responding to mails accordingly. • • • • Error-free processing (100% Accuracy) Maintaining TAT Productivity (Achieve the daily targets) Key Results and Outcomes driven by this role: 0- 5 years Relevant Experience No of years of experience 0-5 years None Demonstrated abilities if any Technical Competencies • Analytical Skills • • Basic Computer knowledge Type writing skills • • Communication skills Decision Making Behavioral competencies

Role & responsibilities Process cashless and reimbursment claims (Should have knowledge of processing retail policies of National/United/New India/Oriental insurance companies. Preferred candidate profile BAMS/BUMS/BHMS Fresher or max 2 years experience in the similar field. Ready to work in shifts

Roles and Responsibilities Design and deliver training programs for international voice process teams, focusing on soft skills, accent reduction, customer service, sales, and product knowledge. Develop and maintain relationships with clients to understand their requirements and preferences for training delivery. Collaborate with subject matter experts to create engaging and effective learning materials. Monitor the effectiveness of trained employees through evaluation metrics such as quality scores, call audits, and feedback from customers. For further information kindly connect with- Simran Rana - 9137514621

Greetings!!! Openings at Sagility for Process Trainer(US Healthcare) Minimum of 4 years of experience as a Process Trainer in an International BPO. Excellent written and verbal communication skills, with strong interpersonal abilities. Proven experience as a Trainer in an International BPO environment. Strong presentation and Excel skills. Sound knowledge of basic training methodologies. Ability to work in US rotational shifts. Immediate joiners are mostly preferred. Interested candidates can share your resume to anitha.c@sagilityhealth.com

Dear Applicant, Hiring for US Healthcare (SQL) - TM Level : TM Location - Hyderabad Work mode : WFO Shift : US shift Years of exp : 7 yrs CTC - Up to 15lpa Qualification : any Graduate Notice period : Immediate , 30 days Skills : US Health Care Domain Knowledge. E.g. Encounters, EDI, HIPAA, 837 Layout, insights into Medicare and Medicaid Markets etc. Facets or any other healthcare adjudication system knowledge will be added advantage. SQL Server SSIS and SSRS plus any Microsoft cloud technologies will be added advantage. Analytical and Query Writing Skills(SQL) SQL Procedure and Packages Debugging skills. Knowledge on any reporting tools or software e.g. Tableau or Power BI etc. PPT Presentations with client. Should be good at communication skills. Interested candidates contact HR Hema@9136535233/ hemavathi@careerguideline.com

We are hiring!! HR Recruiter: Arun Kumar Industry: ITES/BPO Category: International Non-Voice Division: Healthcare International Business We are looking for enthusiastic candidates with excellent communication to join our team as Customer Support Associates in the International Non-Voice Process for Healthcare. Job Title: CSA and Senior CSA Grade: H1/H2 Function/Department: Operations Reporting to: Team Lead Role Description: Roles & Responsibilities (Indicative not exhaustive) A claims examiner needs to analyse multiple documents / contracts and decide to pay / deny the claim submitted by member or providers with respect to client specifications. The claims examiner should also route the claim to different department or provider / member for any missing information that required for claims adjudication. The claims needs to be completed adhering to required TAT and quality SLA. Key Results Production, Quality Shift and Schedule adherence Process Knowledge Minimum Eligibility: Candidates should have minimum 1 year Experience in Claims Adjudication & Claims Adjustment or Claims Adjudication with Appeals & Grievances. Shift Details: Night shift / Flexible to work in any shift and timingCab Boundary Limit: Up to 30 km (One way drop cab) Job Location: Firstsource Solution Limited,5th floor ETA Techno Park, Block 4, 33 OMR Navallur, Chennai, Tamil Nadu 603103.Landmark near Vivira Mall. Contact: Arun HR Phone: 8015721106 Email: arun.kumar9@firstsource.com If you are interested please share your updated CV to the arun.kumar9@firstsource.com or 8015721106 Join us to be part of a dynamic team with career growth opportunities. We look forward to seeing you at the interview! You can refer your friends as well! Disclaimer: Firstsource follows a fair, transparent, and merit-based hiring process. We never ask for money at any stage. Beware of fraudulent offers and always verify through our official channels or arun.kumar9@firstsource.com

Role & responsibilities Candidates with 1-3 years of experience in Insurances process Knowledge of commercial administrative processes. Basic knowledge of Casualty loss exposures presented by Fortune 1000 customer base preferred. Working Knowledge of MS Office. High Level of commitment towards given deadlines. Self-motivated, discipline, good time management skills & demonstrates high levels of energy. Good problem solving and trouble shooting ability as well as flair for improvisation. Preferred candidate profile Perks and benefits

Role & responsibilities To give Claims & Cashless/preauthorization, and scrutiny Medical Reimbursement Claims, and to Process Claims Third Party Administration (Health) services (TPA) Claims and Preauthorization Processing HealthCare Assistance Services High Ratio Claims Management in coordination with Networking and Empanelment Department Monitoring the overall operations of Claims and Preauthorization. Responsible for ensuring efficient response at the level of Preauthorization to maintain TAT. Ensure adherence to processes and controls. Creating the process for claim processing (Cashless and Reimbursement). Co-ordination between Network Hospitals/Preauthorization/Claims. Ensuring a high-quality patient care at customized/optimized cost. Creating the process for claim processing (Cashless and Reimbursement). Preferred candidate profile • Good Excellent oral and written communication, negotiation, and decision-making skills. • Good customer service/relationship skills and ability to work effectively in a fast-paced environment with shifting priorities . Must be willing to work in non - clinic TPA EXPERIENCE mandatory.Clinical Exp.

Greetings!!! Openings at Sagility for Process Trainer-Enrollment(US Healthcare) Minimum of 4 years of experience as a Process Trainer in an International BPO. Excellent written and verbal communication skills, with strong interpersonal abilities. Proven experience as a Trainer in an International BPO environment. Strong presentation and Excel skills. Sound knowledge of basic training methodologies. Ability to work in US rotational shifts. Immediate joiners are mostly preferred. Interested candidates can share your resume to anitha.c@sagilityhealth.com

SUMMARY Job Title: Healthcare Claims Associate German Language Location: Powai, Mumbai Experience Level: 1 6 years Employment Type: Full-time Shift: UK shift Job Summary: We are looking for a detail-oriented and multilingual professional to join our healthcare operations team as a Healthcare Claims Associate with fluency in German . The ideal candidate will be responsible for processing, reviewing, and validating healthcare claims in accordance with company policies and healthcare regulations. Fluency in German is essential as the role involves interpreting and processing claims originating from German-speaking regions. Key Responsibilities: Review, verify, and process healthcare claims using internal systems. Analyze submitted medical documents and ensure compliance with insurance policies. Translate and interpret medical and insurance documents from German to English and vice versa. Communicate with German-speaking clients, hospitals, or insurance providers as required. Identify and flag any inconsistencies or fraudulent claims. Collaborate with internal teams to resolve claim issues and escalate when needed. Maintain accurate records and documentation of all claim activities. Ensure adherence to SLAs and quality metrics. Qualifications & Skills: Bachelor's degree in Healthcare, Business Administration, or a related field. Fluency in German (B2/C1 level or higher) verbal and written. 1 6 years of experience in healthcare claims processing or insurance domain preferred. Strong understanding of medical terminology and healthcare billing systems. Familiarity with ICD, CPT codes, and healthcare regulations is a plus. Excellent communication, analytical, and problem-solving skills. Ability to work in a fast-paced and deadline-driven environment. Experience with tools like Facets, QNXT, or other claims adjudication systems is a plus. Preferred: Certification in German language (Goethe, TestDaF, or equivalent). Experience working with European or German healthcare clients.

Job Location : Hyderabad Qualification - Graduate Work mode Work from office Shift timing 1:00 PM IST to 12:00 AM IST Team leader - 12 lpa Team Manager - 15 lpa Notice 0-60 days US Health Care Domain Knowledge. E.g. Encounters, EDI, HIPAA, 837 Layout, insights into Medicare and Medicaid Markets etc. Facets or any other healthcare adjudication system knowledge will be added advantage. SQL Server SSIS and SSRS plus any Microsoft cloud technologies will be added advantage. Analytical and Query Writing Skills(SQL) SQL Procedure and Packages Debugging skills. Knowledge on any reporting tools or software e.g. Tableau or Power BI etc. PPT Presentations with client. Should be good at communication skills. Best regards, Manish Chauhan HR Executive | Career Guideline Mumbai / Bangalore 9136520859 manish@careerguideline.co.in

Greetings!!! Openings at Sagility for Process Trainer-Enrollment(US Healthcare) Minimum of 4 years of experience as a Process Trainer in an International BPO. Excellent written and verbal communication skills, with strong interpersonal abilities. Proven experience as a Trainer in an International BPO environment. Strong presentation and Excel skills. Sound knowledge of basic training methodologies. Ability to work in US rotational shifts. Immediate joiners are mostly preferred. Interested candidates can share your resume to anitha.c@sagilityhealth.com

Role & responsibilities Candidate should have sound medical/technical underwriting knowledge to process Life and Health Insurance applications & proposals (Underwriting). He/she should have good decision-making ability referring to standard guidelines and principles. Productivity is the key KPI for this process and should engage in full time production. As a process lead, he or she should handle team queries, give expert opinion for the TM, cascade the process updates, conduct refresher training. Should drive for the team accuracy and achieve KPI goals for the team (productivity, TAT, pend%, quality %) Should act as back-up for AM in performing monthly QC, query handling, reporting to client, dashboard preparation, addressing priorities in day-to-day activity. Work collaboratively with other TMs and support adjudication in complex cases. Operational task management which include (but not limited to) ISMS documentation, QMS documentation, RCA, Error analysis. Should have better communication skills, attend client calls, prepare minutes and address customer requirement. Need to create resilience within team/cross training when required. Flexible in time and shift as and when there is a need. Preferred candidate profile Graduate from a recognized university Medical or paramedic and with minimum of 4-5 years of Life and Health insurance underwriting experience. Underwriting certification (optional), training skills and ability to lead a team of paramedics and or underwriters. Clinical experience will have an added advantage Fluency in English speaking, reading and writing

Greetings from NTT DATA, Roles and Responsibilities: Process Adjudication claims and resolve for payment and Denials Knowledge in handling authorization, COB, duplicate, pricing and corrected claims process Knowledge of healthcare insurance policy concepts including in network, out of network providers, deductible, coinsurance, co-pay, out of pocket, maximum inside limits and exclusions, state variations Ensuring accurate and timely completion of transactions to meet or exceed client SLAs Organizing and completing tasks according to assigned priorities. Developing and maintaining a solid working knowledge of the healthcare insurance industry and of all products, services and processes performed by the team Resolving complex situations following pre-established guidelines Requirements: 3-8 years of experience in processing claims adjudication and adjustment process Experience of Facets is an added advantage. Experience in professional (HCFA), institutional (UB) claims (optional) Both under graduates and post graduates can apply Good communication (Demonstrate strong reading comprehension and writing skills) Able to work independently, strong analytic skills **Required schedule availability for this position is Monday-Friday 5.30PM/3.30AM IST (AR SHIFT). The shift timings can be changed as per client requirements. Additionally, resources may have to do overtime and work on weekends basis business requirement. Interested Candidate Please share me your Resume to Ganga.Venkatasamy@nttdata.com