Role & responsibilities Selected trainees Will be trained on Claim adjudication process They will evaluate and processes claims in accordance with company policies and procedures per CMS guidelines/SOP Reviews and analyzes data for in-process claims in order to identify and resolve errors prior to final adjudication Exercises good judgment and remains knowledgeable in related company policies and procedures Achieves teamwork, production and quality standards in order to assure timely, efficient and accurate claims processing Gain knowledge of Commercial, Medicaid, Medicare & TPA claims processing guidelines Knowledge of medical coding/billing including ICD-10, CPT, CMS-1500, UB-04 etc. Knowledge of different providers payment methodologies (i.e., capitation, fee for service based on RBRVS, Medicaid and other negotiated flat rates, RVS pricing, Per Diem, DRG pricing, etc.) preferred Pay or deny per the guidelines/SOP Maintain confidentiality of all information, policies, and procedures as required by the Health Insurance Portability and Accountability Act (HIPAA) protocols Flexibility with shift according to client need is mandatory He/She will report to Team Lead Fresher with good analytical and communication can attempt for Trainee Preferred candidate profile Fresher who can work in NIGHT SHIFTS ( US Shift timings ) Company transport not available Perks and benefits ESI and PF benefits

Role & responsibilities Java developer with in depth knowledge , Data base technologies Knowledge of Claims processing and Benefits set in payer space US health care domain . Hands on Knowledge of Java developement is a preferred skill Preferred candidate profile Experienced Java developers with Database management experience of min of 5 years who can lead the dept and having good knowledge in Claims processing and US health care domain , Benefits set up in Payer space . Need min of 3 to 5 years experience in both development and health care space This is Work from Office role at Chennai ( US timings)

Role & responsibilities We are seeking a dedicated Utilization Management Specialist to join our Chennai office. In this role, you will be responsible for reviewing and analyzing clinical information to determine the medical necessity and appropriateness of healthcare services, ensuring compliance with established guidelines and policies. Your expertise will contribute to optimizing patient care and resource utilization. Key Responsibilities Conduct prior authorization, concurrent, and retrospective reviews for various healthcare services, including inpatient, outpatient, home health, and behavioral health. Apply evidence-based criteria (e.g., MCG, InterQual) to assess the necessity of medical services. Collaborate with healthcare providers, medical directors, and clinical staff to facilitate appropriate care plans and resource utilization. Maintain accurate and organized documentation of all utilization management activities. Participate in quality improvement initiatives and assist in developing clinical guidelines. Monitor and report on utilization trends to management, identifying areas for improvement. Educational qualifications and Experience : Bachelor's Degree in Nursing (BSc Nursing) or equivalent. Minimum of 2 years of clinical experience in a hospital or healthcare setting. Active and unrestricted Registered Nurse (RN) license in the United States. Familiarity with utilization management processes and guidelines (e.g., MCG, InterQual). Proficient in medical terminology, anatomy, and physiology. Strong analytical and problem-solving skills. Excellent communication skills, both written and verbal. Proficient in Microsoft Office applications. Preferred candidate profile Preferred Qualifications Experience with Medicaid, Medicare, and Managed Care programs. Previous experience in utilization review or case management. Certification in Case Management (CCM) or Accredited Case Manager (ACM) is a plus

Role & responsibilities Selected trainees Will be trained on Claim adjudication process They will evaluate and processes claims in accordance with company policies and procedures per CMS guidelines/SOP Reviews and analyzes data for in-process claims in order to identify and resolve errors prior to final adjudication Exercises good judgment and remains knowledgeable in related company policies and procedures Achieves teamwork, production and quality standards in order to assure timely, efficient and accurate claims processing Gain knowledge of Commercial, Medicaid, Medicare & TPA claims processing guidelines Knowledge of medical coding/billing including ICD-10, CPT, CMS-1500, UB-04 etc. Knowledge of different providers payment methodologies (i.e., capitation, fee for service based on RBRVS, Medicaid and other negotiated flat rates, RVS pricing, Per Diem, DRG pricing, etc.) preferred Pay or deny per the guidelines/SOP Maintain confidentiality of all information, policies, and procedures as required by the Health Insurance Portability and Accountability Act (HIPAA) protocols Flexibility with shift according to client need is mandatory He/She will report to Team Lead Fresher with good analytical and communication can attempt for Trainee Preferred candidate profile Fresher who can work in NIGHT SHIFTS ( US Shift timings ) Company transport not available Perks and benefits ESI and PF benefits

Role & responsibilities 3 to 7+ years of experience in testing Healthcare system integrations, including Health Edge, Health Rules Payer (HRP), and claims management systems. Strong expertise in developing and executing End-to-End test strategies for integration projects. Experience in integration testing, regression testing, and system testing across multiple healthcare platforms. Familiarity with risk management in testing, including identifying,assessing, and mitigating testing risks. In-depth experience with environment management for testing, ensuring environments are prepared for integration and validation. Strong knowledge of EDI, HL7, and healthcare claims processes. Proven experience in defect tracking, test reporting, and utilizing test management tools. Lead end-to-end QA efforts for HealthRules Payer implementations and upgrades Collaborate with cross-functional teams to define test strategies, plans, and automation frameworks Ensure compliance with healthcare regulations and business requirements Act as the SME for HRP capabilities, configurations, and workflows Preferred candidate profile Extensive experience in QA for healthcare payer systems, especially HealthRules Payer Testing Strong understanding of claims processing, benefits configuration, and provider management Excellent leadership, problem-solving, and communication skills Experience with test automation tools and agile methodologies a plus