Associate - Claims; Appeals & Grievances - US Healthcare

Position: Associate - Claims (Appeals & Grievances) - US Healthcare
Job Description:

Associate – Claims Adjudication (Appeals & Grievances)

Location:

OMR Navalur, Chennai, Tamil Nadu

Experience:

1–3 Years

Shift: US Shift (5:00 PM – 2:00 AM IST)

Employment Type:

Full‑Time

Role Overview :

We are looking for a detail‑oriented Associate – Claims Adjudication with hands‑on experience in Appeals and Grievances within US healthcare. The role involves reviewing, analyzing, and resolving appealed and grievance claims in compliance with payer guidelines, regulatory requirements, and internal SLAs.

Key Responsibilities:

- Adjudicate appeals and grievance claims accurately and within defined TATs
- Review medical records, claim history, EOBs, provider correspondence, and payer policies
- Interpret US healthcare policies, benefit plans, CPT, ICD‑10, and HCPCS codes
- Ensure compliance with CMS, HIPAA, and payer‑specific guidelines
- Identify claim errors, root causes, and recommend corrective actions
- Document claim decisions clearly and maintain audit‑ready records
- Meet productivity, quality, and accuracy benchmarks consistently
- Collaborate with QA, team leads, and downstream teams for issue resolution
- Escalate complex or high‑risk cases appropriately

Required Skills &

Qualifications:

- 1–3 years of experience in US healthcare claims adjudication
- Mandatory experience in Appeals and Grievances
- Strong knowledge of:
- Claims lifecycle and adjudication rules
- Medical coding (CPT, ICD‑10, HCPCS)
- Payer policies and benefit interpretation

- Good analytical and decision‑making skills
- Strong written and verbal communication skills
- Comfortable working in US shifts
- Proficiency in claims processing systems and MS Office

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