We are looking for a Claim Handler - OPD Claims, responsible for reviewing, evaluating, and processing insurance claims as per company policies and regulatory guidelines. The role involves medical document review, claim assessment, customer coordination, and claim-related calling while ensuring accuracy, quality, and timely resolution.
Key Responsibilities
- Evaluate, review, and process claims in accordance with company policies, procedures, productivity, and quality standards.
- Examine medical documents and assess claim admissibility based on policy terms and conditions.
- Review medical claims and verify information for accuracy and completeness.
- Coordinate with customers over calls to explain policy terms & conditions, claim details, claim status, and documentation requirements.
- Handle customer queries related to claims and provide timely updates/resolutions.
- Deliver excellent customer service by addressing policyholder concerns professionally.
- Identify discrepancies in claims and coordinate for corrections or additional information.
- Examine claims for potential fraud indicators and conduct investigations wherever required.
- Gather additional information/documents to determine the validity of claims.
- Ensure compliance with company policies, processes, and regulatory requirements.
- Maintain productivity and quality standards as per defined expectations.
- Process claim payments accurately as per approvals and guidelines.
- Adapt to cross-training opportunities and manage multiple claim-related activities.
- Perform other claim-related tasks as required.
Required Skills & Competencies
- Good communication skills in English and Hindi (mandatory).
- Comfortable with customer coordination and customer calling.
- Solid customer service skills.
- Good medical knowledge and understanding of medical terminology.
- Basic understanding of insurance claims process (preferred).
- Basic knowledge of IRDAI guidelines will be an added advantage.
- Strong analytical and problem-solving skills.
- Attention to detail and ability to verify documents accurately.
- Ability to multitask and adapt to process requirements.
- Basic knowledge of MS Office (Excel, Word, Outlook).
Qualification (Mandatory):
- Candidate must hold a medical degree/qualification such as:
- B.Pharm
- Pharm D
- B.Sc Nursing
- BDS
- BHMS
- BAMS
- Any other relevant medical/healthcare qualification
- Freshers can apply.
- Candidates with prior experience in health insurance claims, medical claims processing, or healthcare operations will be preferred.
Work Details
- Work Mode: Work from Office (WFO)
- Working Days: 6 days working
- Weekly Off: 1 rotational week off
- Shift Timings: General shift timings
- Transport Facility: Not provided
- Languages Required: English and Hindi mandatory
- Candidate should be open for customer calling and customer coordination as part of the role.