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 & Sk

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