Process Specialist - US


: $36,560.00 - $58,890.00 /year *

Employment Type

: Full-Time


: Healthcare - Allied Health

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Job Description

Claim Policy SME- Aguadilla, Puerto Rico

In the role of process specialist, you will execute transactions as per prescribed guidelines and timelines, reviews and validates the inputs from the other team members, support your manager in training activities, daily operations reviews and help in escalation resolution with the objective to meet service level agreement targets for the specific process within the guidelines, policies and norms of Infosys.

In this role you will be responsible for transition coordination, process training and certifications for the team, talent management related activities, Service Level Agreement compliance and Process compliance. You will also be involved in day to day customer interactions, knowledge management and process reengineering activities.

Location for this position is Aguadilla, Puerto Rico

Basic Qualifications

* High School Diploma or GED Equivalent

* Minimum 18 to 36 months in Healthcare claims area

* Minimum 12 months' experience of process training (stand-up trainer) and claims audit specialist is required


* SME support and mentoring team

* Provide guidance, training, quality audits and supervision to assist staff in achieving goals for production, processing time and accuracy

* Prepare question log, RCA for errors and plan actions

* Reviews cases which have been forwarded for any expert help because of any inaccuracy, data unavailability etc.

* Reviews and communicates updates and changes

* Responsible for accurate and timely processing of Healthcare claim service request and processing claims

* Reviews, evaluates the service request as per SOP

* Familiar with Medical Policy, Familiar with UCSW service requests, correspondence inquiries and image review

* Forward the cases to appropriate teams, post the in-scope activities have been completed as per SOP

* Prep medical records for clinical review

* End to end processing and resolution of clinical claims and correspondence

* Understand/interpret medical terminology including clinical notes and reports

* Able to review medical policies and determine the appropriate claim processing or clinical review process decisions (pay, request additional records, refer for clinical review)

* Review and determine pricing for clinical claims in accordance with negotiated pricing agreements

* Adept knowledge of verifying member benefits, eligibility verification and medical necessity determination

* Lotus Notes where the Medical Policy Database, NAEGS and OTT Database are housed

* Should be knowledgeable in the use of intranet (OLI, Image, Sharepoint etc) and internet (CareRadius, Encoder Pro, EviCore etc) applications

* NASCO claim processing ? adjustments and manual pricing

Domain Experience:

* Experience in Healthcare Claims adjudication

* Requires in depth knowledge of CPT, ICD-9/10, and HCPC codes

* Strong PC Skills. Must be proficient in Microsoft word and able to draft manual letters

* Basic numeracy and aptitude skills

* Experience in any claim adjudication platform

* Team work

* Must be detailed oriented

* Critical thinking and problem solving

Note: Applicants for employment in the U.S. must possess work authorization which does not require sponsorship by the employer for a visa (H1B or otherwise).

The job entails sitting as well as working at a computer for extended periods of time. Should be able to communicate by telephone, email or face to face.

About Us

Infosys BPM, the business process management subsidiary of Infosys (NYSE: INFY), provides end-to-end transformative services for its clients across the globe. The company's integrated IT and BPM solutions approach enables it to unlock business value across industries and service lines, and address business challenges for its clients. Utilizing innovative business excellence frameworks, ongoing productivity improvements, process reengineering, automation, and cutting-edge technology platforms, Infosys BPM enables its clients to achieve their cost reduction objectives, improve process efficiencies, enhance effectiveness, and deliver superior customer experience. Infosys BPM has 32 delivery centers in 14 countries spread across 6 continents, with 35,058 employees from over 80 nationalities, as of March, 2018.

The company has been consistently ranked among the leading BPM companies globally and has received over 60 awards and recognitions in the last 5 years, from key industry bodies and associations like the Outsourcing Center, SSON, and GSA, among others. Infosys BPM also has very robust people practices, as substantiated by the various HR-specific awards it has won over the years. The company has consistently been ranked among the top employers of choice, on the basis of its industry leading HR best practices. The company's senior leaders contribute widely to industry forums as BPM strategists.

Associated topics: blood collection, hematopathology, mlt, molecular, pathology, technician i, technician iii, technician iv, technologist, toxicology * The salary listed in the header is an estimate based on salary data for similar jobs in the same area. Salary or compensation data found in the job description is accurate.

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