Job Title: Medico - Claims Case Management

Location: Thane

Experience: 25 Years

Education: MBBS / BAMS / BHMS

Job Summary:

We are looking for a Claims professional to manage Travel and OPD health insurance claims. The candidate will be responsible for claim audits, claim processing, MIS reporting, and ensuring timely claim settlement while coordinating with external partners.

Key Responsibilities

1. Claim Review

- Review health insurance claims for admissibility, irregularities, overbilling, unnecessary procedures and policy compliance.
- Conduct root-cause analysis using claims data, treatment records, provider contracts and standard treatment guidelines.
- Assess medical documentation and treatment appropriateness for claim decisions.

2. Cost Management & Utilization Review

- Review plan of care, medical necessity, admissibility and cost-effectiveness.
- Identify opportunities to control unnecessary healthcare costs and minimize claim disputes.
- Monitor adherence to insurer-provider contracts, IRDAI guidelines and internal policies.
- Conduct audits of high-risk claims and hospital billing practices.

3. Communication & Stakeholder Management

- Liaise with network hospitals, doctors, TPAs and internal stakeholders such as Claims, Underwriting and FWA teams.
- Coordinate with hospitals in real time to clarify discrepancies and resolve claim-related issues.
- Negotiate with healthcare providers to ensure adherence to approved treatment protocols and facilitate timely claim resolution.
- Identify non-compliance and drive corrective action through effective communication.

4. Documentation, Data Analysis & Reporting

- Maintain accurate records of case progress,



findings and resolutions.
- Analyse claims trends and identify recurring issues, irregularities and potential risks.
- Prepare reports with findings and recommendations for process improvement.

5. Patient Advocacy & Quality Improvement

- Support customer-focused claim resolution while maintaining medical and policy compliance.
- Educate internal and external stakeholders on ethical practices, billing abuse, policy terms and contractual requirements.
- Stay updated on healthcare regulations, medical coding standards and emerging fraud/waste/abuse patterns.

Knowledge Requirements

- Strong understanding of Health Insurance Claims and Cashless Claims processes.
- Knowledge of TPA operations and insurer-provider contracts.
- Understanding of health insurance policy terms and clinical protocols.
- Knowledge of ICD-10 / CPT medical coding is preferred.
- Good understanding of IRDAI guidelines and insurance processes.
- Knowledge of hospital billing, medical necessity and utilization review.

Candidate Requirements

- MBBS / BAMS / BHMS mandatory.
- Minimum 4 years of experience in Insurance / TPA.
- Individual Contributor experience preferred.
- Candidates with experience in Claims, Provider Network, Claim Investigation or Medical Claims will be preferred.
- Strong communication, negotiation and stakeholder management skills.
- Strong clinical knowledge with analytical and problem-solving ability.
- Positive knowledge of MS Excel and PowerPoint.
- Candidates should be comfortable working in a Work From Office setup.
- Willingness to work on Saturday/Sunday as per roster, with compensatory weekly offs.
- Candidates should be within the 26-38 years age range.

📌 Medico Claims Case Management (Thane)
🏢 TopGear Consultants
📍 Thane