Claims Processing Executive

Key Responsibilities: Claims Processing: Review, validate, and process healthcare claims submitted by providers in accordance with US insurance policies. Core platform – QNXT claims experienced - Preferred MUST HAVE CLAIMS and FACETS experience Eligibility Verification: Confirm patient coverage, benefits, and pre-authorization requirements under Medicare, Medicaid, and private insurance plans. Adjudication: Approve, deny, or adjust claims based on payer guidelines and policy terms. Compliance: Maintain adherence to HIPAA regulations, CMS guidelines, and other US healthcare compliance standards. Documentation: Record claim activity, maintain audit trails, and prepare reports for management.

Required Skills & Qualifications: High school diploma or equivalent REQUIRED Strong knowledge of US healthcare insurance systems (Medicare, Medicaid, commercial payers). 2–4 years of experience in US healthcare claims processing Familiarity with claims management software and EDI transactions. Excellent analytical, organizational, and communication skills. Ability to interpret insurance policies and payer guidelines. Detail-oriented with strong problem-solving abilities.

Competencies: Regulatory Knowledge – Deep understanding of US healthcare laws and payer requirements. Accuracy & Detail Orientation – Ensures claims are processed correctly and efficiently. Problem-Solving – Resolves claim disputes and denials effectively.