Role & responsibilities

1. Cashless Claim Processing

- Review and process cashless health insurance claims received from hospitals/TPAs/insurers.
- Scrutinize pre-authorization requests, medical documents, treatment details, diagnosis, and proposed treatment plans.
- Verify policy coverage, eligibility, exclusions, waiting periods, and applicable terms and conditions.
- Assess the medical necessity and appropriateness of the proposed treatment.
- Review hospital estimates, investigation reports, prescriptions, clinical notes, and other relevant documents.
- Process approvals, queries, enhancements, denials, and final authorizations within defined TAT.
- Coordinate with hospitals, insurance companies, TPAs, doctors, and internal teams for missing information or clarification.
- Ensure appropriate medical and non-medical deductions are applied as per policy guidelines.
- Maintain accuracy and quality while meeting defined productivity and TAT targets.
- Escalate complex, high-value, doubtful, or potentially fraudulent cases to the appropriate authority.

1. Reimbursement Claim Processing

- Review reimbursement claims submitted by insured members after hospitalization/treatment.
- Verify claim forms, bills, discharge summaries, prescriptions, investigation reports, medical records, and other supporting documents.
- Validate hospitalization details, diagnosis, treatment, duration of stay, and expenses against policy coverage.
- Assess admissibility of medical expenses as per policy terms and applicable guidelines.
- Identify non-payable, inadmissible, duplicate, unrelated, or unsupported expenses.
- Review pre- and post-hospitalization expenses wherever applicable.
- Raise appropriate queries for incomplete, inconsistent, or insufficient documentation.
- Process payable, partially payable, repudiated,



or non-payable claims based on applicable policy terms.
- Ensure proper documentation and justification for claim decisions.
- Maintain defined TAT, accuracy, quality, and productivity standards.

1. Medical Claim Assessment

- Analyze clinical information, diagnosis, treatment protocols, investigations, and hospitalization records.
- Determine whether the treatment and hospitalization are medically justified based on available records.
- Identify discrepancies between diagnosis, treatment, documentation, and claimed expenses.
- Provide appropriate medical opinions for complex or doubtful cases.
- Identify potential misrepresentation, non-disclosure, fraud, abuse, and policy violations.
- Escalate cases requiring specialist review or further investigation.

1. Quality & Compliance

- Ensure all claims are processed strictly as per policy terms, SOPs, client guidelines, and regulatory requirements.
- Maintain high accuracy and quality standards while processing claims.
- Ensure complete and appropriate documentation of every claim decision.
- Follow defined escalation matrix and claim-processing workflows.
- Maintain confidentiality and security of insured/patient information.
- Participate in quality audits and implement corrective actions for identified errors.

1. Productivity & TAT Management

- Achieve assigned daily/monthly claim-processing targets without compromising quality.
- Ensure timely closure of cases within defined TAT.
- Monitor pending, query, enhancement, and overdue cases.
- Prioritize cases based on TAT, urgency, claim type, and client requirements.
- Provide timely updates on cases approaching or exceeding TAT.
- Maintain individual productivity and contribute to overall team performance.

Preferred candidate profile TPA or health insurance background

📌 Walk-in || Medical Officer (Noida)
🏢 Authentic HealthCare
📍 Noida