Role & responsibilities
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.




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, an

📌 Walk In Medical Officer Noida
🏢 Authentic HealthCare
📍 Noida