Claims Examiner II

Role Overview Smart Data Solutions, a leading healthcare process automation and interoperability company, is hiring a Claims Examiner II to join its growing operations team in Chennai. In this role, you will be responsible for accurately reviewing, adjudicating, and resolving moderately complex medical, dental, and vision claims in line with client-specific policies, regulatory standards, and internal procedures. You will work with a degree of independence and may also support escalated cases and guide junior team members. Key Responsibilities - Review, research, and adjudicate healthcare claims including professional, institutional, dental, and vision claims based on plan documents, contracts, and applicable regulations such as CMS and HIPAA - Process claims using standard forms including CMS-1500, UB-04, and ADA, along with medical coding systems such as ICD-10, CPT, HCPCS, and Modifiers - Resolve system pends, claim edits, and denials through thorough investigative research and proper documentation - Apply appropriate payment methodologies including fee schedules, capitation, coordination of benefits, and other reimbursement rules - Update provider and member records to ensure accurate claim routing and correct payment processing - Independently manage a claims workload to meet turnaround time and quality benchmarks - Respond to inquiries and escalations via shared inboxes within agreed SLA timelines - Maintain detailed and audit-ready documentation of all claim actions and resolutions in the claims system - Collaborate with internal departments to resolve cross-functional issues and support process improvement initiatives - Ensure full compliance with HIPAA data privacy standards and internal security protocols - Participate in department meetings, calibration sessions, peer reviews, and ongoing training activities Required Qualifications - High school diploma or equivalent is required - Minimum 2 years of experience in healthcare claims processing - Hands-on experience with standard claim forms CMS-1500, UB-04, and ADA - Familiarity with the full claims lifecycle workflow and coordination of benefits - Practical knowledge of medical code sets including ICD-10, HCPCS, CPT, and modifiers - Experience in claim repricing or provider and member demographic updates - Strong attention to detail, accuracy, and ability to prioritise work in a high-volume environment - Good written and verbal communication skills with the ability to adapt to process changes - Preferred: 3 or more years of experience in a health plan or TPA claims environment, knowledge of Medicare or Medicaid programs, and exposure to repricing tools or claim pricing methodologies Why Join Us Smart Data Solutions offers a collaborative and growth-oriented work culture where your contributions directly impact client success. You will benefit from a 5-day work week, hybrid work flexibility, professional development opportunities, and a workplace that values innovation and work-life balance.

- Minimum 2 years of experience in healthcare claims processing - Experience with CMS-1500, UB-04, and ADA claim forms - Knowledge of ICD-10, CPT, HCPCS, and modifiers - Familiarity with claims lifecycle and coordination of benefits - Experience in claim repricing or demographic updates - Strong attention to detail and accuracy - Good written and verbal communication skills - Ability to work independently and meet deadlines in a high-volume environment - Knowledge of HIPAA and data privacy standards

- Hybrid and remote work opportunities - 5-day work week - Leaves as per the Labour Law of India - Professional development and growth-oriented work environment - Collaborative and innovative company culture