Claim Review:
Review the claims for admissibility, noted irregularities, overbilling, or unnecessary procedures.
Conduct root-cause analyses of claims using claims data, treatment records, and provider contracts, standard treatment guidelines and protocols
Cost Management, Utilization Review:
Review plan of care medical necessity and admissibility with cost effectiveness and minimizing claim disputes

Monitor adherence to insurer-provider contracts, IRDAI guidelines, and internal policies.
Conduct audits of high-risk claims and hospital billing practices.
Communication and Collaboration for Resolution
Liaise with network hospitals, doctors and internal stake holders (claims, underwriting, FWA) / Third-Party Administrators (TPAs), to resolve disputes in real time for customer.




Identify non-compliance and get corrective action on identified non-compliant 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.
Documentation, data analysis & Reporting
Maintain records of case progress, Identify trends
Prepare and maintain reports on findings, recommendations for process improvements.
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.

📌 Claims Executive Thane (India)
🏢 TopGear Consultants
📍 India