ADJUDICATOR

About Connect and Heal

Connect and Heal Primary Care Pvt. Ltd. is a leading integrated healthcare services provider, committed to delivering accessible, high-quality, and technology-enabled primary care solutions. Our ecosystem brings together emergency response, telemedicine, outpatient services, corporate health, and wellness programs to improve patient outcomes and enhance organizational health.

Role Overview

The Adjudication Specialist will play a critical role in ensuring accurate, timely, and compliant processing of healthcare claims and cases. The role involves reviewing medical documentation, validating clinical necessity, and ensuring that claims are adjudicated as per policy, regulatory, and contractual guidelines. The individual will work closely with medical, operations, and compliance teams to uphold quality, transparency, and efficiency in the adjudication process.

Key Responsibilities

• Review, validate, and process healthcare claims, ensuring adherence to company policy, provider contracts, and regulatory standards.
• Assess medical records and clinical documentation to confirm eligibility, coverage, and appropriateness of services claimed.
• Ensure accurate coding (ICD, CPT, HCPCS) and alignment with medical necessity criteria.
• Identify discrepancies, incomplete information, or potential fraud/abuse cases, and escalate where required.
• Collaborate with the medical review board, doctors, and operations teams to resolve adjudication queries.
• Maintain turnaround time (TAT) and service-level agreements (SLAs) for claim processing.
• Document adjudication decisions clearly and consistently in the system.
• Support internal and external audits by providing data and clarifications.
• Recommend process improvements to enhance efficiency, reduce errors, and strengthen compliance.

Required Qualifications & Skills

• Graduate degree in healthcare, life sciences, or related field (Nursing, Pharmacy, MBBS, BDS preferred).
• 2–5 years of experience in healthcare adjudication, medical review, or claims processing.
• Strong knowledge of health insurance policies, medical coding systems (ICD, CPT, DRG, HCPCS), and adjudication guidelines.
• Familiarity with healthcare regulations (IRDAI, NABH, HIPAA preferred).
• Excellent analytical skills with attention to detail and accuracy.
• Ability to interpret clinical documentation and medical terminology.
• Strong communication and documentation skills.
• Proficiency in MS Office and healthcare adjudication software.

Key Competencies

• Integrity and compliance orientation.
• Analytical and problem-solving ability.
• High attention to detail with process discipline.
• Ability to work under pressure and meet deadlines.
• Collaboration and cross-functional communication.

Job Types: Full-time, Permanent

Pay: ₹400,000.00 - ₹550,000.00 per year

Benefits:

• Health insurance
• Provident Fund

Work Location: In person