Sme Claims Hc Kochi

Job Summary Serve as a subject matter expert for health care claims within a hybrid global delivery model focusing on accurate adjudication and compliance with HIPAA regulations. Apply deep knowledge of payer and provider processes to resolve complex claim issues support continuous process improvement and enhance member and provider satisfaction during night shift operations. Responsibilities Review complex health care claims to ensure accurate adjudication aligned with payer policies and benefit designs minimizing financial leakage and rework while operating during night shift schedule. Apply advanced knowledge of provider contracting terms and reimbursement methodologies to validate claim payments and identify discrepancies that impact providers and members. Analyze claim routing coding patterns and adjudication outcomes to detect systemic issues recommend rule updates and support improvements in auto adjudication performance. Coordinate with operations configuration and quality teams to clarify benefit rules resolve escalated claim cases and ensure timely closure of high priority items for payer clients. Interpret and implement HIPAA transaction standards for claim related data ensuring that all handled records comply with privacy and security requirements in every workflow step. Conduct root cause analysis on claim denials payment variances and age out backlogs then document transparent action plans that drive measurable reduction in repeat issues. Prepare concise production reports and trend summaries that highlight service level adherence defect drivers and productivity insights for continuous process refinement. Guide team members on best practices in claims adjudication provider data usage and benefit interpretation by sharing reference materials and practical case examples. Collaborate with technology and configuration partners to validate system changes participate in user acceptance testing and confirm that recent rules accurately reflect payer and provider req .