Claims Examiner II

Job Title: Claims Examiner II

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About us:

For over 20 years, Smart Data Solutions has been partnering with leading payer organizations to provide automation and technology solutions enabling data standardization and workflow automation. The company brings a comprehensive set of turn-key services to handle all claims and claims-related information regardless of format (paper, fax, electronic), digitizing and normalizing for seamless use by payer clients. Solutions include intelligent data capture, conversion and digitization, mailroom management, comprehensive clearinghouse services and proprietary workflow offerings. SDS’ headquarters are just outside of St. Paul, MN and leverages dedicated onshore and offshore resources as part of its service delivery model. The company counts over 420 healthcare organizations as clients, including multiple Blue Cross Blue Shield state plans, large regional health plans and leading independent TPAs, handling over 500 million transactions of varying types annually with a 98%+ customer retention rate. SDS has also invested meaningfully in automation and machine learning capabilities across its tech-enabled processes to drive scalability and greater internal operating efficiency while also improving client results.

SDS recently partnered with a leading growth-oriented investment firm, Parthenon Capital, to further accelerate expansion and product innovation.

Location: 6th Floor, Block 4A, Millenia Business Park, Phase II MGR Salai, Kandanchavadi, Perungudi, Chennai- 600096

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. To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed above are representative of the knowledge skill and or ability required. Reasonable accommodation may be made to enable individuals with disabilities to perform essential job functions. Due to access to Protected Healthcare Information, employees in this role must be free of felony convictions on a background check report.

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