- Claims Assessment: Evaluate and process health insurance claims in accordance with policy terms and conditions.
- Medical Review: Identify and flag potential cases of medical abuse or discrepancies in treatment protocols.
- Admissibility Decision: Determine claim eligibility based on thorough review of medical documentation and policy guidelines.
- Tariff Adjudication: Review and authorize cashless approvals, ensuring alignment with applicable tariffs and negotiated rates.
- Stakeholder Coordination: Liaise effectively with internal teams, network hospitals, and other external stakeholders to ensure smooth claim processing and resolution.
Qualifications & Skills:
- MBBS/BAMS/BHMS or equivalent medical qualification (preferred).
- Solid understanding of health insurance policies and medical terminology.
- Analytical mind-set with attention to detail.
- Excellent communication and decision-making skills.
- Ability to work collaboratively in a fast-paced environment.
- Flexible to work in rotational shifts
Experience Required: 4-5 years in Health Insurance Claims/Underwriting/Investigation etc. fresher with clinical skills also ok