Claims Examiner I

Job Titile: Claims Examiner I

Do you see…? Are you passionate about …?  

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
  
 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 I is responsible for accurately reviewing and processing routine medical, dental, and vision claims according to established guidelines, benefit policies, and regulatory standards. This entry-level role is ideal for individuals looking to grow in the healthcare claims industry. Under supervision, the Claims Examiner I learns claims adjudication procedures, applies appropriate coding and fee schedule rules, and helps support the accuracy and timeliness of claims processing

Duties and Responsibilities include, but are not limited to:

Responsibilities 

• Review and process healthcare claims (e.g., CMS-1500, UB-04, ADA) using standard operating procedures (SOPs), benefit plans, and claim system edits.
• Apply basic coding (ICD-10, CPT, HCPCS, modifiers) and reimbursement rules during claim adjudication.
• Verify member eligibility, benefits, and provider information to ensure proper claims payment.
• Adhere to production and quality standards and established turnaround times.
• Respond to assigned internal inquiries, emails, or audit items in a timely and professional manner.
• Document claim decisions and actions clearly in the claim processing system.
• Participate in training, calibration, and quality assurance activities to improve consistency and compliance.
• 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.
• Escalate complex or unclear claims to senior examiners or leads for resolution guidance.

Qualifications

• High school diploma or equivalent required
• 1-2 year(s) of experience in healthcare claims processing or related administrative work
• Familiarity with claim forms (CMS-1500, UB-04 and ADA) and basic medical terminology
• Ability to navigate multiple systems, toggle between screens, and enter data efficiently
• 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
• Willingness to learn, accept feedback, and grow within a team

Preferred candidates possess:

• Experience working with claims systems (e.g., Javelina, WLT, or VBA)
• Basic knowledge of ICD-10, CPT, and HCPCS coding structures
• Understanding of insurance concepts such as deductibles, copays, coinsurance, or COB.
• Experience in the health care industry working with Health Plans or Third-Party Administrators.
• Knowledge of Medicare, Medicaid, or other government programs