Claims Adjudication Executive (Khajaguda)

Job Summary: We are looking for a Claims Adjudication qualified to review and process insurance claims accurately and efficiently. The role involves verifying eligibility, reviewing claim documents, applying policy and benefit rules, and making appropriate claim decisions while maintaining quality and turnaround time. Key Responsibilities: - Review and process insurance claims and supporting documents. - Verify member eligibility, policy coverage, and date-of-service details. - Check claims for completeness and validate relevant medical information and codes. - Apply policy terms, benefit rules, limits, sub-limits, tariffs, and applicable pricing guidelines. - Determine claim outcomes, including approval, partial approval, or denial. - Identify potential billing anomalies, overutilization, and fraud/waste/abuse indicators. - Ensure claim accuracy, compliance, quality standards, and required TAT/SLAs. - Support denial, appeals, grievance, and claim-related queries when required. - Coordinate with internal teams, providers, and other stakeholders for claim resolution. Required Skills: - Good understanding of insurance claims and claim processing. - Strong analytical and decision-making skills. - Good attention to detail and documentation skills. - Ability to work within defined TATs and quality standards. - Good communication and coordination skills. - Knowledge of ICD, CPT, and HCPCS codes is an advantage. Compensation: 15,000.00 - 25,000.00 per month Work Location: In person .