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
Skills Required
- Graduation is mandatory
- Minimum 4–5 years of claims adjudication experience
- 5+ years of experience in claims processing or claims adjudication
- Strong knowledge of U.S. healthcare
- Ability to perform payment determination and calculate allowable amounts without system support
- Ability to identify revenue gaps and opportunities through claims review and data mining
- Strong written and oral communication skills
- Ability to complete assigned inventory within turnaround-time and quality standards
- Ability to prepare and update production, quality, and status reports
- Ability to work independently with minimal guidance
- Ability to follow compliance protocols and HIPAA guidelines
- Experience with post-adjudication or overpayment projects
- Neutral accent
- Broadband high-speed internet connection for telecommuting
What We Do
Choosing a digital partner is about more than capabilities — it’s about collaboration and character. Unrealistic overhauls and off-the-shelf products ignore what matters most — your unique needs, culture, goals, and your legacy data and technology environments. At EXL, our collaboration is built on ongoing listening and learning to adapt our methodologies. We’re your business evolution partner—tailoring solutions that make the most of data to make better business decisions and drive more intelligence into your increasingly digital operations. Whether your goals are scaling the use of AI and digital, redesign operating models, or driving better and faster decisions, we’re here to partner with you to help you gain—and maintain—competitive advantage with efficient, sustainable models at scale. Our expertise in transformation, data science, and change management helps make your business more efficient and effective, improve customer relationships and enhance revenue growth. Instead of focusing on multi-year, resource- and time-intensive platform designs or migrations, we look deeper at your entire value chain to integrate strategies with impact. We use our specialization in analytics, digital interventions, and operations management—alongside deep industry expertise — to deliver solutions that help you outperform the competition. At EXL, it’s all about outcomes—your outcomes—and delivering success on your terms. Share your goals with us and together, we’ll optimize how you leverage data to drive your business forward. For more information, visit www.exlservice.com.
