Medical Claims & Coding Specialist

Job Description

Job Overview: We are seeking an experienced and detail-oriented Medical Claims Auditor & Processor to join our growing team focused on self-funded and level-funded US healthcare plans . This hybrid role combines responsibilities in claims processing and auditing to ensure accuracy, compliance, and efficiency across our Third Party Administrator (TPA) operations. The ideal candidate will have hands-on experience in medical coding, claims adjudication, and quality assurance, with a strong understanding of US healthcare regulations. Key Responsibilities: Process and audit medical claims for accuracy, eligibility, coding (ICD-10, CPT, HCPCS), and compliance with plan benefits and regulatory standards. Conduct pre-payment and concurrent audits on claims for self-funded and level-funded health plans. Review plan documents alongside claim codes to determine appropriate benefit application. Ensure claims are processed in alignment with federal/state regulations including HIPAA, ERISA, and ACA . Identify and resolve discrepancies through collaboration with providers, examiners, and internal teams. Maintain detailed and accurate documentation of audit findings and processed claims. Respond to inquiries from providers, members, and stakeholders with professionalism and accuracy. Maintain strict confidentiality of all patient and provider information. Contribute to continuous improvement efforts and internal quality assurance programs. Required Qualifications: Minimum 3 years of experience in medical claims auditing and/or processing within a US healthcare TPA or insurance setting. Medical coding certification is mandatory (e.g., CPC, CPMA, CCS, CBCS). In-depth knowledge of medical terminology , coding systems (ICD-10, CPT, HCPCS), and healthcare claims forms ( CMS-1500 , UB-04 ). Familiarity with self-funded and level-funded health plan structures and benefits administration. Strong understanding of HIPAA, ERISA, ACA , and other applicable healthcare regulations. Proficient in Microsoft Office Suite and healthcare claim systems. Preferred Experience With: Claims adjudication platforms : Trizetto, VBA, Plexis Electronic Medical Records (EMR/EHR) and audit management systems Working in fast-paced, compliance-driven environments with high attention to detail Job Type: Full-time Pay: ₹400,000.00 - ₹800,000.00 per year Benefits: Health insurance Leave encashment Paid sick time Paid time off Provident Fund Schedule: Fixed shift Monday to Friday Night shift US shift Ability to commute/relocate: Malad, Mumbai, Maharashtra: Reliably commute or planning to relocate before starting work (Preferred) Experience: Medical Claims Processing: 3 years (Preferred) Medical coding: 3 years (Preferred) License/Certification: Medical Coding Certification (Preferred) Shift availability: Night Shift (Required) Work Location: In person