UST
Website:
ust.com
Job details:
Role Description
Contract : 6 Month
Job Title: Senior Claims Adjuster, US Healthcare (Payer)
Shift: 5:30 PM - 2:30 AM IST (US Shift)
Experience: 5+ Years (Payer-Side Mandatory)
Role Summary
We are looking for a highly skilled Senior Claims Adjuster with deep expertise in payer-side claims adjudication, including complex claims adjustments, to support high-impact US healthcare operations. The role demands strong analytical capability, system knowledge, and the ability to interpret payer guidelines with precision in a Healthcare environment.
Key Responsibilities
- Perform end-to-end claims adjudication and adjustments for professional and institutional claims
- Handle complex claims adjustments, including:
- Multi-line claims
- Pricing/reimbursement corrections
- Contract/fee schedule interpretation
- Coordination of Benefits (COB) scenarios
- Review and validate eligibility, benefits, authorizations, and medical necessity (non-clinical)
- Investigate and resolve denials, appeals, reprocessing, and exception cases
- Ensure accurate application of payer policies, business rules, and reimbursement methodologies
- Work on manual adjudication scenarios where auto-processing fails
- Ensure compliance with HIPAA, client SLAs, and quality benchmarks
- Support RCA, audits, and continuous improvement initiatives
- Act as an SME/mentor for junior team members
Required Skills & Expertise
- Strong experience in payer-side claims adjudication and adjustments
- Proven ability to handle complex claims scenarios independently
- Deep knowledge of:
- Claims lifecycle
- EOB interpretation
- Pricing logic & reimbursement methodologies
- Expertise in CPT, ICD-10, HCPCS coding systems
- Hands-on experience with payer platforms; HealthRules knowledge preferred
- Strong analytical, problem-solving, and decision-making skills
- Ability to manage high-volume workloads with high accuracy
- Effective communication skills (client & internal stakeholders)
Eligibility Criteria
- Minimum 5+ years of experience in US Healthcare payer claims adjudication
- Mandatory experience in BPO / KPO environment
- Graduate
- Certifications such as Certified Professional Coder (CPC) are an added advantage
Preferred Qualifications
- Experience in complex/high-dollar claims handling
- Exposure to automation / AI-assisted claims adjudication tools
- Experience in quality audits / SME / team handling roles
- Knowledge of Medicare, Medicaid, and Commercial plans
As Part Of UST, Candidates Are Expected To Demonstrate
- Humility: Respectful collaboration and openness to feedback
- Humanity: Empathy towards members, providers, and colleagues
- Integrity: Ethical processing and strict adherence to compliance
- Customer Focus: Delivering high-quality outcomes aligned with client expectations
- Excellence: Continuous improvement and ownership of results
Skills
claims adjudication,healthcare operations,coordination of benefits,pricing,institutional claims,analytical skills,quality audit,
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