Job Description: Process Executive (PE) - Claims Adjudication: Job Summary: We are seeking a detail-oriented and motivated Process Executive (PE) to join our growing US Healthcare Operations team. As a fresher, you will undergo comprehensive training to evaluate, validate, and adjudicate medical claims submitted by healthcare providers. Your core objective will be to ensure that every claim is processed accurately, efficiently, and in strict compliance with industry rules and policy guidelines. Key Responsibilities: Claim Review: Analyze electronic and paper medical claims for completeness, accuracy, and compliance with Standard Operating Procedures (SOPs). Data Verification: Verify patient eligibility, coverage benefits, medical codes (ICD-10, CPT), and provider details. Adjudication Decisions: Process claims that route out of automatic adjudication to determine whether to pay, reduce, or deny the claim based on policy rules. Discrepancy Resolution: Identify and flag billing errors, duplications, or missing information that prevent clean claim processing. Metrics & Turnaround: Meet daily individual production targets (quantity) while maintaining high quality and accuracy standards (98%+). Compliance: Ensure 100% confidentiality of sensitive patient data in strict accordance with HIPPA regulations.
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