Job description – Claims processors

Job Purpose

To review and adjudicate inpatient reimbursement claims by validating medical documentation, policy terms, and insurer protocols, ensuring accurate, timely, and compliant claim processing.

Principal Accountabilities

Process inpatient reimbursement claims accurately and within TAT as per insurer and organizational guidelines.

Review and validate medical documents (diagnoses, procedures, discharge summaries) against policy and coding standards.

Escalate complex or out-of-limit cases to the Team Manager/Medical Specialist for timely resolution.

Ensure compliance with regulatory, insurer, and organizational requirements while maintaining audit-ready records.

Coordinate with hospitals for clarifications and support managers in resolving insurer or customer queries.

Reporting Structure:

Reports To: Floor Manager – Claims

Major Challenges

Managing high claim volumes while maintaining TAT and accuracy.

Interpreting diverse insurer policies consistently.

Balancing quick turnaround with thorough document scrutiny.

Coordinating with hospitals and internal stakeholders under strict deadlines.

Decisions

Independent:



Adjudication of standard pre-authorization cases as per policy terms.

With Approval: Escalations requiring specialist opinion, insurer concurrence, or deviations from package norms.

Interactions

Internal: Claims team, Case Management, CRM team.

External:

Hospitals through Query (for discharge summaries, clarifications, and missing documents).

Insurers (for concurrence and escalations).

Qualifications & Experience

Education: Graduates -BHMS/BAMS/BDS

Experience:

Fresher medical graduates can apply.

Prior experience in Pre-Authorization / Claims management in a TPA or HealthTech setup preferred.

Exposure to authorization or reimbursement processes is an added advantage.

Team Lead: 3+ years of experience in the same domain.

Other requirements:

Robust medical knowledge with willingness to work in a non-clinical, process-driven role.

Good analytical and decision-making ability.

Effective written and verbal communication skills.

Proficiency in MS Office (Excel, Word, Outlook).

Flexible to work in shifts as per business requirements.

📌 Medical Officer - Ranchi (India)
🏢 Vidal Health Insurance TPA
📍 India