Key Responsibilities

1. Claim Processing

Review, assess, and process various types of health insurance claims including

reimbursement claims, OPD claims, and pre-authorization requests. Ensure all submitted

documents are complete, valid, and meet the insurer’s requirements before proceeding with

claim evaluation.

2. Medical Adjudication

Analyze medical documents such as prescriptions, invoices, diagnostic reports, and

discharge summaries to evaluate medical necessity. Ensure that treatments and procedures

are clinically justified and fall within the coverage guidelines defined by the insurance

policy.

3. Financial Accuracy

Accurately calculate the admissible claim amount by applying policy-specific conditions

such as room rent capping, sub-limits, co-payments, and proportionate deductions. Ensure

all financial calculations are exact and well-documented to avoid discrepancies.

4. Compliance and Policy Adherence

Ensure that all claim decisions strictly adhere to the policy terms and conditions, insurer

guidelines, and applicable regulatory requirements. Maintain consistency and fairness in

claim adjudication to minimize errors and escalations.

5. Data Management and Documentation





Perform accurate data entry in claim processing systems and maintain detailed records of

all claim decisions including approvals, partial approvals, and denials. Ensure proper

documentation for audit and future reference.

6. Workflow and TAT Management

Efficiently manage high claim volumes by prioritizing high-value and time-sensitive cases.

Ensure all claims are processed within the defined Turnaround Time (TAT) while

maintaining quality and accuracy.

Required Qualifications and Skills

- Doctor of Pharmacy (PharmD) is mandatory.

- Minimum 1 year of experience in healthcare claims processing or medical adjudication.

- Strong understanding of medical terminology, treatments, and clinical documentation.

- Knowledge of health insurance policies, claim processes, and adjudication guidelines.

- Proficiency in MS Office, especially Excel, for data analysis and reporting.

- Strong analytical skills with attention to detail.

- Ability to manage workload efficiently and meet deadlines.

Pay: ₹15,020.02 - ₹38,528.45 per month

Work Location: In person

📌 Claims Executive (India)
🏢 Connect And Heal Primary Care Private
📍 India