PFB JD for Case Management TM (team member)

Job Position: AM / DM / Manager

Location: Thane Mumbai

Department: Ops Claims

Job Summary:

We are seeking detailoriented individuals to join in our highly energetic and fast 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 costeffective 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 ficial losses, and uphold the integrity of the claims process while collaborating with internal teams and external healthcare providers with customer centric approach.

Key Responsibilities:

1. Claim Review :

Review the claims for admissibility, noted irregularities, overbilling, or unnecessary procedures.

Conduct rootcause 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 insurerprovider contracts, IRDAI guidelines, and internal policies.

Conduct audits of highrisk claims and hospital billing practices.

3. Communication and Collaboration for Resolution

Liaise with network hospitals, doctors and internal stake holders (claims, underwriting, FWA) / ThirdParty Administrators (TPAs), to resolve disputes in real time for customer.

Identify noncompliance and get corrective action on identified noncompliant 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 Reporting

Maintain records of case progress, Identify trends

Prepare and maintain reports on findings, recommendations for process improvements.

5. Patients advocacy, continuous Learning and quality improvement:

Educate internal and external stake holders on ethical practices and billing abuse, policy / contract terms

Stay updated on healthcare regulations, coding standards (ICD, CPT), and emerging fraud tactics.

Education :
Bachelor s degree in Medicine (MBBS/BAMS/BHMS), MBA in Healthcare Management, or related field.

Experience :
Minimum 23 yrs. experience preferably in Hospitals TPA department, Health Insurance, Claim processing, Claim investigation,

Knowledge Requirement:

Familiarity with cashless claim processes, TPAs, and insurerprovider contracts.

Understanding of health insurance policy terms, Clinical protocols, medical coding (ICD10, CPT), IRDAI guidelines

Skills:

Strong clinical knowledge and analytical and problemsolving abilities.

Excellent communication for negotiations and stakeholder collaboration.

Proficiency and knowledge of MS Excel, PowerPoint and/or analytics tools

Knowledge of health insurance terms and IRDA guideline

Customer first approach and detail oriented

Key Competencies:

High ethical standards and attention to detail.

Ability to manage multiple cases in a fastpaced environment.

Critical thinking to assess complex claims and billing patterns.
Quick learner and Process oriented.

Work Environment

Work from Office, 5 working days in a week

Disclaimer: This job posting has been aggregated from external source. Role details, content, and availability are subject to change. Applicants are advised to confirm the latest information directly on the company website before applying.

📌 Team Member - Case Management Professional (Thane)
🏢 Aditya Birla Insulators
📍 Thane