Job Description

Key Responsibilities

Claims Adjudication & Escalation Management

• Manage accurate adjudication of US medical claims as per defined guidelines and policies
• Handle escalations, resolve issues, and ensure proper documentation
• Ensure compliance with insurance policies, procedures, and regulatory standards

Team Management & Leadership

• Provide coaching and feedback to team members to improve performance
• Support new hires and accelerate their learning curve
• Conduct regular performance reviews and manage team productivity
• Manage staffing to meet operational requirements and shrinkage targets
• Drive initiatives to reduce attrition and improve engagement

Performance & Quality Management

• Monitor transactions regularly and implement corrective actions
• Ensure achievement of all SLA/KPIs (quality, productivity, turnaround time)
• Identify opportunities for process improvement and implement enhancements
• Maintain high standards of work quality and accuracy

Stakeholder & Client Interaction

• Communicate proactively with internal and external stakeholders
• Build and maintain strong relationships with clients and business partners
• Handle client interactions at supervisory level when required

Reporting & Compliance

• Ensure timely and accurate reporting of internal and external metrics
• Support audits by collecting and providing required data
• Ensure adherence to internal policies, external regulations, and information security standards

Core Competencies

Data Gathering & Problem Solving

• Gather relevant data from multiple sources and identify key issues
• Generate and evaluate solutions to determine the most effective outcome

Business Awareness

• Understand business operations and contribute to initiatives that enhance competitive advantage

Customer Focus

• Deliver high-quality service by understanding and addressing customer needs

Teamwork & Collaboration

• Work collaboratively with teams and respect organizational priorities

Managing Self

• Plan, prioritize, and execute tasks efficiently to meet deadlines

Adaptability

• Remain effective in a dynamic, fast-changing work environment

Work Standards

• Maintain high personal performance and quality benchmarks

Required Skills & Qualifications

• Medical Graduated are preferred
• Strong knowledge of US Medical Insurance Claims, processes, and procedures
• Understanding of US geography and culture
• Familiarity with quality standards and compliance requirements
• Excellent problem-solving and analytical skills
• Strong organizational skills with high attention to detail
• Excellent English communication (written and verbal)
• Good business writing skills (grammatically and contextually accurate)
• Ability to work on desktop systems and relevant applications

Behavioral Skills

• Customer service orientation
• Quality-driven mindset
• Strong interpersonal and stakeholder management skills
• Empathy for coaching and team development

Additional Requirements

• Willingness to work in night shift and WFO
• Ensure consistent achievement of KPIs
• Proactive communication on daily operational issues
• Continuous focus on quality, productivity, and customer satisfaction

Key Responsibilities

Claims Adjudication & Escalation Management

• Manage accurate adjudication of US medical claims as per defined guidelines and policies
• Handle escalations, resolve issues, and ensure proper documentation
• Ensure compliance with insurance policies, procedures, and regulatory standards

Team Management & Leadership

• Provide coaching and feedback to team members to improve performance
• Support new hires and accelerate their learning curve
• Conduct regular performance reviews and manage team productivity
• Manage staffing to meet operational requirements and shrinkage targets
• Drive initiatives to reduce attrition and improve engagement

Performance & Quality Management

• Monitor transactions regularly and implement corrective actions
• Ensure achievement of all SLA/KPIs (quality, productivity, turnaround time)
• Identify opportunities for process improvement and implement enhancements
• Maintain high standards of work quality and accuracy

Stakeholder & Client Interaction

• Communicate proactively with internal and external stakeholders
• Build and maintain strong relationships with clients and business partners
• Handle client interactions at supervisory level when required

Reporting & Compliance

• Ensure timely and accurate reporting of internal and external metrics
• Support audits by collecting and providing required data
• Ensure adherence to internal policies, external regulations, and information security standards

Core Competencies

Data Gathering & Problem Solving

• Gather relevant data from multiple sources and identify key issues
• Generate and evaluate solutions to determine the most effective outcome

Business Awareness

• Understand business operations and contribute to initiatives that enhance competitive advantage

Customer Focus

• Deliver high-quality service by understanding and addressing customer needs

Teamwork & Collaboration

• Work collaboratively with teams and respect organizational priorities

Managing Self

• Plan, prioritize, and execute tasks efficiently to meet deadlines

Adaptability

• Remain effective in a dynamic, fast-changing work environment

Work Standards

• Maintain high personal performance and quality benchmarks

Required Skills & Qualifications

• Medical Graduated are preferred
• Strong knowledge of US Medical Insurance Claims, processes, and procedures
• Understanding of US geography and culture
• Familiarity with quality standards and compliance requirements
• Excellent problem-solving and analytical skills
• Strong organizational skills with high attention to detail
• Excellent English communication (written and verbal)
• Good business writing skills (grammatically and contextually accurate)
• Ability to work on desktop systems and relevant applications

Behavioral Skills

• Customer service orientation
• Quality-driven mindset
• Strong interpersonal and stakeholder management skills
• Empathy for coaching and team development

Additional Requirements

• Willingness to work in night shift and WFO
• Ensure consistent achievement of KPIs
• Proactive communication on daily operational issues
• Continuous focus on quality, productivity, and customer satisfaction

Required Skills & Qualifications

• Medical Graduated are preferred
• Strong knowledge of US Medical Insurance Claims, processes, and procedures
• Understanding of US geography and culture

EXL (NASDAQ: EXLS) is a leading data analytics and digital operations and solutions company. We partner with clients using a data and AI-led approach to reinvent business models, drive better business outcomes and unlock growth with speed. EXL harnesses the power of data, analytics, AI, and deep industry knowledge to transform operations for the world’s leading corporations in industries including insurance, healthcare, banking and financial services, media and retail, among others. EXL was founded in 1999 with the core values of innovation, collaboration, excellence, integrity and respect. We are headquartered in New York and have more than 54,000 employees spanning six continents. For more information, visit www.exlservice.com EXL never requires or asks for fees/payments or credit card or bank details during any phase of the recruitment or hiring process and has not authorized any agencies or partners to collect any fee or payment from prospective candidates. EXL will only extend a job offer after a candidate has gone through a formal interview process with members of EXL’s Human Resources team, as well as our hiring managers.