Claims Auditor

Smart Data Solutions, a leading provider of data management, claim routing and workflow solutions to health plans and TPAs, is looking for a Claims Auditor to join our team!

What you’ll be doing?

• Plan and perform audits of enrollment, eligibility, claims processing, and other operational areas for accuracy, timeliness, and compliance with regulatory and contractual requirements.

• Develop and maintain audit work plans, checklists, sampling methodologies, and audit schedules.

• Review case files, transactions, and system records to verify adherence to state and federal healthcare regulations (e.g., Medicaid, Medicare, ACA) and applicable accreditation standards.

• Document audit findings, root causes, and risk levels in clear, well-organized audit reports.

• Present audit results to management and collaborate with department leaders on corrective action plans.

• Track and follow up on corrective action items to confirm timely remediation and closure.

• Support internal audits, as needed.

• Maintain audit documentation in accordance with organizational retention and confidentiality requirements.

• Identify trends and systemic issues across audit results and recommend process improvements.

• Serve as an escalation point for claims that cannot be resolved by processors, ensuring accurate and timely resolution.

• Process claims directly on an occasional basis (e.g., during ramp-up/ramp-down periods, backlog reduction, or urgent processing needs), applying the same standards of accuracy and timeliness expected of examining staff.

• Participate in departmental and client training and calibration meetings as needed to maintain consistency between audit and processing standards.

• Ensure compliance with all client requirements, regulatory guidelines, and internal policies, including HIPAA.

• Flexible working in any shift & performing other duties as assigned.

• Work from office is mandatory

The duties set forth above are essential job functions for the role. Reasonable accommodations may be made to enable individuals with disabilities to perform essential job functions.

What we’re looking for?

Required skills:

• Minimum 5+ years of experience in healthcare claims examining and/or audit/compliance.

• Proven ability to handle complex claims scenarios, including COB, appeals, and high-dollar claims.

• Ability to mentor and support junior team members in a production environment.

• Advanced knowledge of ICD-10, CPT, HCPCS coding, and claims processing best practices.

• Knowledge of medical claim forms (e.g., HCFA, CMS-1500, UB-04, ADA) and familiarity with Medicare/Medicaid program requirements.

• Ability to read and interpret Standard Operating Procedure (SOP) documents, job aids, and edit resolution guidance to support occasional direct claims processing.

• Strong analytical skills with the ability to identify discrepancies, trends, and root causes from data and documentation.

• Proficiency with claims systems and Microsoft Office tools

• Strong written and verbal communication skills.

• Ability to work independently and as part of a team in a high-volume, deadline-driven environment.

• High attention to detail and organizational skills; ability to manage multiple audits and deadlines simultaneously.

• Preferred: experience in a large health plan or third-party administrator (TPA) environment.

Location: Chennai, India

Why this company is for you?

Top Benefits & Perks:

• A company culture that is authentic, innovative, and collaborative! Our most powerful strength is our people! We build impactful solutions for our customers - their success is our success!

• A professional development and growth-oriented workplace

Who is Smart Data Solutions?

Smart Data Solutions (SDS) is a technology leader in healthcare process automation and interoperability. As a strategic partner, SDS helps clients digitally transform their operations, delivering tangible value through reduced costs, streamlined workflows, and an improved customer experience. With data, AI, and automation at its core, SDS provides solutions in Digital Mailroom and Data Capture, Clearinghouse, Intelligent Medical Records, Prior Authorization and Claim Operations. Trusted by over 500 clients—including multiple Blue Cross Blue Shield plans, regional health plans, TPAs, providers, and healthcare partners—SDS streamlines complex front, middle, and back-office operations.

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.