We are seeking detailoriented individuals to join in our highly agile 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
Maintai
📌 Team Member (Thane)
🏢 Aditya Birla Insulators
📍 Thane
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