PFB JD for Case Management TM (team member)

Job Position: AM / DM / Manager
Location: Thane Mumbai
Department: Ops Claims

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Job Summary:
We are seeking detail-oriented individuals to join in our highly dynamic and rapid growing case management team in claims operations.
It involves the timely coordination of quality healthcare services to address a client’s specific needs in a cost-effective manner to promote optimal outcomes for customers.
This role focuses on reviewing, analysing the claims, identifying and resolving the abuse, inflation in claims, adherence to policy terms.
The ideal candidate will ensure compliance with policies, prevent financial losses, and uphold the integrity of the claims process while collaborating with internal teams and external healthcare providers with customer centric approach.

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Key Responsibilities:
1. Claim Review:
- Review the claims for admissibility, noted irregularities, overbilling, or unnecessary procedures.
- Conduct root-cause analyses of claims using claims data, treatment records, and provider contracts,



standard treatment guidelines and protocols
2. Cost Management, Utilization Review:
- Review plan of care medical necessity and admissibility with cost effectiveness and minimizing claim disputes
Monitor adherence to insurer-provider contracts, IRDAI guidelines, and internal policies.
- Conduct audits of high-risk claims and hospital billing practices.
3. Communication and Collaboration for Resolution
- Liaise with network hospitals, doctors and internal stake holders (claims, underwriting, FWA) / Third-Party Administrators (TPAs), to resolve disputes in real time for customer.
- Identify non-compliance and get corrective action on identified non-compliant via direct communication for quick resolution.
- Real time coordination with hospitals to clarify discrepancies and ensure adherence to approved treatment protocols for facilitating best customer experience during their claim.
4. Documentation, data analysis & Rep

📌 Team Member (Thane)
🏢 Financial services
📍 Thane