SPE-Claims HC

About the Role

Serve as a claims adjudication specialist within a global healthcare services organization applying strong expertise in MS Excel and medical claims processing for provider and payer domains. Contribute to accurate, timely, and compliant evaluation of healthcare claims in a hybrid work model with night shifts, supporting operational excellence and better health outcomes.

Key Responsibilities

• Review healthcare claims for provider and payer accounts with careful attention to policy rules, eligibility criteria, and benefit structures to ensure accurate adjudication and reduce payment errors.
• Analyze claim data in MS Excel using filters, lookups, pivot tables, and structured worksheets to identify discrepancies, trends, and patterns that support continuous improvement in claim handling.
• Validate key claim elements such as member information, provider details, coding consistency, and billed amounts to help maintain high levels of data integrity and regulatory compliance.
• Apply adjudication guidelines and standard operating procedures consistently across all assigned claims to ensure fair processing outcomes and strengthen trust among healthcare stakeholders.
• Coordinate with internal operations and quality teams to clarify claim-related questions and document resolutions that improve process efficiency and reduce repeat issues.
• Maintain detailed and well-organized claim tracking logs in spreadsheet templates to monitor status, turnaround times, and escalations, supporting transparent reporting to management.
• Respond to claim inquiries from authorized internal partners in a timely and professional manner, providing clear explanations of adjudication decisions that support customer satisfaction.
• Collaborate with colleagues in the hybrid work environment to share best practices in MS Excel usage, claim interpretation, and payer or provider rules, promoting a culture of knowledge sharing.
• Follow defined controls for night shift operations, including adherence to cut-off times, productivity targets, and quality metrics, to support global service levels with minimal disruption.
• Support audit readiness by maintaining accurate digital records and standardized documentation of claim decisions, enabling thorough review and continuous enhancement of control frameworks.
• Contribute to process optimization initiatives by suggesting refinements to templates, checklists, and validation steps, helping the company improve cost-effectiveness and healthcare affordability.
• Adhere to privacy and confidentiality requirements when handling sensitive member and provider information, thereby protecting individual rights and reinforcing organizational integrity.
• Participate in training sessions and updates related to regulatory changes, payer policies, and provider contracting rules, ensuring that claim adjudication remains current and compliant.

Qualifications

• Demonstrate practical experience using MS Excel for data entry, validation, analysis, and reporting in a production environment with strong attention to accuracy and consistency.
• Exhibit hands-on exposure to claims adjudication workflows in healthcare, including verification, coding interpretation, and resolution of discrepancies for both provider and payer scenarios.
• Show understanding of provider operations such as billing practices, contract terms, and reimbursement models, enabling precise evaluation of claims and reductions in disputes.
• Apply knowledge of payer processes including benefit structures, policy provisions, and denial management approaches to support correct payment decisions and lower rework volumes.
• Display strong analytical and problem-solving abilities with capacity to investigate claim issues methodically and propose data-based solutions that support smoother operations.
• Communicate clearly in written and verbal form with cross-functional stakeholders, explaining complex claim outcomes in accessible language that helps drive informed decisions.
• Adapt effectively to hybrid working arrangements and night shift schedules while maintaining high productivity and meeting defined accuracy thresholds and performance expectations.

Certifications

• Preferred certification in medical claims processing or health insurance, such as Certified Professional Coder (CPC) or equivalent.