Returnship Tm Claims Hc Pune

Job Summary This hybrid night shift role focuses on end to end health care claims adjudication and compliance driven processing using HIPAA standards within payer and provider environments ensuring accurate decisions reduced leakages and improved member and provider experience for a global client base while contributing to high quality timely claim outcomes and sustainable business value. Responsibilities Analyze complex health care claims with strong focus on HIPAA compliance and adjudication rules to deliver accurate and timely claim decisions that support client service excellence and financial integrity for payer and provider organizations. Apply detailed knowledge of perks coverage policies and coordination of benefits to interpret claim data and determine appropriate payment or denial outcomes that minimize rework and prevent revenue leakage. Review claim edits audits and exception queues to validate rule application and propose refinements that enhance auto adjudication rates while maintaining regulatory and contractual compliance. Collaborate with payer operations provider relations and technical configuration teams in a hybrid mode to clarify benefit designs fee schedules and contract terms that influence claim outcomes and member impact. Document claim decisions rationales and adjustments in transparent structured formats that enable downstream analytics audit readiness and transparent communication to internal stakeholders and external partners. Identify recurring adjudication issues such as coding discrepancies or benefit misinterpretations and coordinate with configuration and policy teams to drive sustainable remediation and continuous improvement. Monitor night shift operational metrics such as turnaround time queue aging and quality scores to prioritize daily work and escalate risk items that may affect service level commitments. Perform root cause analysis on claim disputes rejections and appeals to recommend corrective actions that reduce future e .