Sr Associate - Health claims (CL&MR)

Key Responsibilities

• File Review & Assessment

• Review all open claim files assigned (cashless & reimbursement).

• Verify completeness of documentation (pre-authorization forms, discharge summaries, bills, prescriptions, investigation reports, etc.).

• Check for missing or inconsistent information and initiate follow-ups with hospitals, TPAs, or claimants.

• Evaluate medical necessity of treatments against standard guidelines and policy coverage.

• Identify any non-payable items, exclusions, or excess billing.

• Policy & Compliance Verification

• Ensure all claims are adjudicated as per policy wordings, benefit plans, exclusions, and sub-limits (if applicable).

• Maintain compliance with IRDAI regulations and company SOPs.

• Escalate potential cases of fraud, abuse, or misrepresentation to the investigation team.

• Coordination & Communication

• Liaise with medical panel doctors, TPAs, hospital coordinators, and internal claims teams for clarifications.

• Provide accurate updates on claim status and pending requirements.

• Ensure professional and clear communication with all stakeholders.

• Quality & Process Improvement

• Track claim pendency, turnaround time (TAT), and provide periodic reports on open files.

• Contribute to process improvements to minimize open file pendency.

• Assist in root cause analysis for delays and recommend corrective measures.

Key Skills & Competencies

• Strong knowledge of health insurance policies, medical terminology, and hospital billing practices .
• Ability to interpret policy wordings, exclusions, and benefit clauses .
• Analytical thinking with attention to detail.
• Good communication and coordination skills.
• Proficiency in MS Office and claims management systems.

Qualifications & Experience

• Graduate MBBS,BAMS,BHMS,BDS.
• 1–4 years’ experience in health insurance claims adjudication, TPA operations, or hospital billing.

Performance Indicators (KPIs)

• Timely closure of open claims within defined TAT.
• Accuracy in claim review and adjudication.
• Reduction in repeated queries or rework.
• Compliance adherence (regulatory and internal SOPs).
• Quality of documentation and escalation.

Key Responsibilities

• Claims Processing & Adjudication

• Receive and validate OPD claims submitted by policyholders (consultation, diagnostics, pharmacy bills, preventive health check-ups, etc.).

• Check claim forms, prescriptions, invoices, and supporting medical documents for accuracy and completeness.

• Verify eligibility, coverage limits, exclusions, and waiting periods under the policy.

• Identify non-payable expenses and process the payable amount as per policy terms.

• Ensure claims are settled within the defined turnaround time (TAT).

• Medical & Financial Scrutiny

• Validate medical necessity for consultations, diagnostics, and prescribed medications.

• Cross-check billing and pricing norms against market standards and internal guidelines.

• Flag suspicious or inflated claims for investigation.

• Coordination & Communication

• Liaise with insured members, hospitals, diagnostic centers, and pharmacies for clarifications or missing documents.

• Escalate complex cases to senior medical officers or investigation team where required.

• Provide clear and professional communication to customers regarding claim approvals, deductions, or rejections.

• Compliance & Quality Assurance

• Adhere to IRDAI regulations and company SOPs in claim adjudication.

• Maintain proper documentation and audit trails for every claim.

Participate in internal audits and quality checks to ensure process compliance.