Job Description & How to Apply Below
What you'll be doing
Summary
The Claims Examiner II is responsible for accurately reviewing, adjudicating, and resolving moderately complex medical, dental, and vision claims in accordance with client-specific policies, regulatory guidelines, and standard operating procedures. Depending on business needs, this role may also support claim repricing, provider and member demographic updates, and related claim administration tasks. The Claims Examiner II works independently and may assist with escalated issues or mentoring junior staff.
Duties And Responsibilities
Review, research, and adjudicate healthcare claims (professional, institutional, dental, vision) based on plan documents, contracts, and applicable regulations (e.g., CMS, HIPAA).
Process claims using standard claim forms (CMS-1500, UB-04, ADA) and appropriate coding systems (ICD-10, CPT, HCPCS, Modifiers).
Resolve system pends, edits, and denials through investigative research and documentation.
Apply proper payment methodologies including fee schedules, capitation, COB, and other reimbursement rules.
Update provider records to ensure accurate claims routing and payment
Process updates to member information in alignment with system rules and business requirements
Independently manage assigned claims to meet turnaround time and quality standards
Respond to inquiries or escalations, including shared email inboxes, within established SLAs.
Accurately document actions and resolutions in claim systems, ensuring transparency and audit readiness.
Collaborate with internal departments to resolve cross-functional claim issues.
Maintain updated knowledge of client-specific workflows, benefit plans, policies, and procedures.
Support process improvement activities, peer review tasks, and training efforts as needed.
Ensure compliance with data privacy standards and internal security protocols (HIPAA, etc.).
Participate in department meetings, calibration sessions, and continuing education.
Qualifications
High school diploma or equivalent required
2+ year(s) of experience in healthcare claims processing
Experience with CMS-1500, UB-04 and ADA forms
Familiarity with claims lifecycle workflows and COB
Knowledge and experience with medical code sets ICD 10, HCPCS, CPT and modifiers
Experience in repricing or demographic updates
Strong attention to detail and accuracy
Effective written and verbal communication
Ability to prioritize work and meet deadlines in a high-volume environment
Comfortable working independently and adapting to process changes
Preferred Candidates Possess
3+ year(s) of experience in health plan or TPA claims environment
Knowledge of Medicare, Medicaid, or other government programs
Exposure to repricing tools or claim pricing methodologies
Why this is the company for you
Top Benefits & Perks
A company culture that is authentic, innovative, and collaborative! Our most powerful strength is our people! We build impactful solutions for our customers - their success is our success!
A professional development and growth-oriented workplace
Work-life balance with a 5-day work week and leaves as per the Labor Law of India
A flexible environment with hybrid and remote work opportunity.
Location : 6th Floor, Block 4A, Millenia Business Park, Phase II MGR Salai, Kandanchavadi, Perungudi, Chennai- 600096
Who is Smart Data Solutions
Smart Data Solutions (SDS) is a technology leader in healthcare process automation and interoperability. As a strategic partner, SDS helps clients digitally transform their operations, delivering tangible value through reduced costs, streamlined workflows, and an improved customer experience. With data, AI, and automation at its core, SDS provides solutions in Digital Mailroom and Data Capture, Clearinghouse, Intelligent Medical Records, Prior Authorization and Claim Operations.
Trusted by over 500 clients—including multiple Blue Cross Blue Shield plans, regional health plans, TPAs, providers, and healthcare partners—SDS streamlines complex front, middle, and back-office operations.
Smart Data Solutions is an equal opportunity employer.
All qualified applicants will receive consideration for employment without regard to race, color, sex, sexual orientation, gender identity, religion, national origin, disability, veteran status, age, marital status, pregnancy, genetic information, or other legally protected status.
4PM - 1 AM
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