Claims Examiner II

Claims Examiner II

Smart Data Solutions, a leading provider of data management, claim routing and workflow solutions to health plans and TPAs, is looking for a Claims Examiner II, to join our team!

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 include, but are not limited to:

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.