Key Roles &

- Responsibilities

- Insurance Claim OperationsManage end-to-end processing of health insurance claims, including cashless and reimbursement cases.
- Handle claim intimation, registration, allocation, processing, adjudication, settlement, and closure.
- Ensure compliance with policy terms, insurer guidelines, IRDAI norms, and internal SOPs.
- Monitor and ensure adherence to defined Turnaround Times (TATs).

Portal &

- System Handling

- Extensive handling of TPA and insurer portals, including:
- Claim intimation and registration
- Uploading and verification of documents
- Raising and responding to insurer/TPA queries
- Tracking approvals, rejections, and settlements
- Final claim closure and documentation

Medical Scrutiny &

- Evaluation

- Perform detailed medical scrutiny of:
- Hospital bills, discharge summaries, and case sheets
- Investigation and diagnostic reports
- Pharmacy bills, consumables, ICU/ward charges
- Operative notes and treatment records
- Assess:
- Medical necessity and diagnosis validation
- Treatment protocol appropriateness
- ICU vs ward justification
- Length of stay and cost reasonableness

Policy Compliance &

- Risk Identification

- Identify and evaluate:
- Pre-Existing Diseases (PED)
- Non-disclosure or misrepresentation
- Policy exclusions and breaches
- Inconsistencies in clinical and billing documents
- Support fraud detection through:
- Clinical correlation
- Billing pattern analysis
- Verification of medical and financial documents

Coordination &

- Communication





- Coordinate with:
- Hospitals, treating doctors, and internal clinical teams
- TPAs, insurance companies, investigators
- Insured members and patient relatives
- Obtain clarifications, additional documents, and medical justifications as required.

Settlement, MIS &

- Compliance

- Calculate claim settlements and coordinate approvals.
- Maintain accurate claim MIS, trackers, and compliance records.
- Handle escalations, grievances, audits, and insurer communications professionally.
- Support internal audits and insurer reviews when required.

Eligibility &

- Skills

Educational Qualification

- Graduate in any discipline
- Preferred: Healthcare Administration / Medical / Insurance-related background

Experience

- Minimum 2 years of experience in:
- Health insurance claims
- TPA / Hospital insurance desk / Insurance company operations

Technical &

- Functional Skills

- Solid knowledge of:
- Health insurance policies & claim workflows
- IRDAI regulations and insurer guidelines
- Cashless and reimbursement claim processes
- Hands-on experience with insurer and TPA portals
- Good understanding of medical terminology and hospital billing
- Proficiency in MS Excel, MIS reporting, and documentation

Soft Skills

- Strong coordination and communication skills
- High attention to detail and analytical thinking
- Ability to manage multiple claims and deadlines
- Ethical, process-oriented, and compliance-driven approach

📌 Insurance Specialist (Pune)
🏢 Atmabodh - Patanjali Wellness Center
📍 Pune