Claims Representative

Job Title

Claims Representative – Healthcare (2–4 Years)

Location: Bengaluru, India (CHSI) | Work Mode: On-site

Function: Healthcare Operations – Claims Administration

Role Summary

The Claims Representative is responsible for end-to-end processing of healthcare claims in alignment with client/payer policies, benefits, and regulatory guidelines. The role requires strong knowledge of claims adjudication, documentation review, accuracy, productivity, and service excellence while meeting SLA/TAT, quality, and compliance requirements.

Key Responsibilities

Claims Processing & Adjudication

Process and adjudicate claims (professional/institutional/ancillary as applicable) using payer guidelines, benefit plans, and standard operating procedures.

Validate claim data (member, provider, eligibility, authorization, diagnosis/procedure codes, modifiers, COB, and documentation) to ensure completeness and accuracy.

Apply appropriate edits, pricing rules, and policy determinations; identify and resolve claim issues, exceptions, and denials.

Perform rework and appeal/adjustment activities when required (correcting claim errors, reprocessing, reconsiderations).

Research, Resolution & Communication

Conduct research using systems/tools (claims platforms, eligibility, provider portals, policy manuals) to resolve pends and denials.

Document clear, audit-ready notes on claim decisions, actions taken, and outcomes.

Collaborate with upstream/downstream teams (Eligibility, Enrolment, Provider Services, Member Services, Adjustments, Payment Integrity) to resolve claim discrepancies.

Quality, Compliance & Controls

Meet or exceed targets for quality, productivity, schedule adherence, and turnaround time.

Ensure compliance with HIPAA/PHI handling, client confidentiality, and internal controls.

Participate in audits, calibrations, refreshers, and continuous improvement initiatives.

Identify recurring issues and propose corrective actions (SOP updates, training needs, system enhancements).

Required Skills & Competencies

Technical / Domain Skills

2–4 years of experience in Healthcare BPO claims operations (International healthcare preferred).

Good understanding of

Claims lifecycle (intake → adjudication → payment/denial → adjustments/reconsiderations)

Eligibility & benefits, prior authorization basics, provider contracting concepts

Common claim types: Professional (1500), Institutional (UB‑04), and/or dental/pharmacy (if applicable)

ICD-10, CPT/HCPCS, modifiers, place of service (working knowledge)

Denial categories and claim edits (medical necessity, coverage, coding, timely filing, COB, duplicate, bundling/unbundling)

Behavioural Skills

Strong attention to detail with high accuracy and strong documentation discipline

Analytical thinking and structured problem solving

Clear written communication for notes, emails, and client documentation

Ability to work in a metric-driven environment and manage priorities independently

Tools (Good to Have)

Experience with claims platforms (e.g., Facets/QNXT/Health Edge/EPIC Tapestry or equivalent), payer portals, and ticketing tools.

Intermediate MS Excel skills (filters, pivots basics) and comfort with multiple systems.

Education & Experience

Graduate in any discipline (life sciences/healthcare background is a plus).

2–4 years relevant experience in healthcare claims processing/adjudication

Performance Measures (KPIs)

Quality/Accuracy: ≥ client-defined target

Productivity: Claims/hour or units/day as per process requirement

SLA/TAT adherence and backlog management

Compliance: 0 tolerance for PHI/HIPAA breaches

Attendance & schedule adherence as per policy

Shift & Work Requirements

Willingness to work in US and EU shifts (evening/night) and rotational schedules as business needs.

About The Cigna Group

Cigna Healthcare, a division of The Cigna Group, is an advocate for better health through every stage of life. We guide our customers through the health care system, empowering them with the information and insight they need to make the best choices for improving their health and vitality. Join us in driving growth and improving lives.