Your typical week might include the following:

- Reviewing and analyzing health-claims-related grievances to ensure accurate, fair, and timely resolution within defined regulatory timelines.

- Conducting detailed medical assessment of claim files, discharge summaries, investigation reports, and clinical notes to validate decisions and ensure fairness.

- Collaborating closely with Claims, Underwriting, Legal, and TPA teams to provide clinical clarity and assist in resolving complex health-related complaints.

- Ensuring grievances received through regulatory and public portals (e.g., Bima Bharosa, IGMS, PG Portal) are closed within prescribed IRDAI timelines.

- Preparing and supporting medical summaries and responses for Ombudsman and litigation cases.

- Identifying recurring medical issues, performing root cause analysis (RCA), and recommending corrective and preventive actions.

- Acting as the voice of the customer, ensuring empathetic, transparent, and accurate communication of medical decisions.

- Contributing to knowledge base creation by documenting medical FAQs, precedents, and claim adjudication guidelines.

- Partnering in process improvement initiatives aimed at enhancing medical accuracy and reducing repeat grievances.

- Supporting service recovery initiatives to transform complaints into opportunities for customer delight and retention.

You could be the right candidate if you:

- Are a qualified medical professional MBBS / BAMS / BHMS / BDS (mandatory).

- Have 68 years of experience in health insurance, TPA operations, hospital administration, or medical audit.

- Possess strong knowledge of IRDAI regulations, claims assessment processes,



and health insurance guidelines.

- Demonstrate the ability to balance clinical accuracy with customer empathy.

- Are comfortable reviewing complex medical documentation and making sound, evidence-based judgments.

- Can collaborate effectively across functions like Claims, Underwriting. Legal, Compliance, and Customer Service.

- Are detail-oriented, disciplined, and capable of working within defined TATs and regulatory norms.

- Have strong written and verbal communication skills to explain complex medical matters in simple, customer-friendly language.

- Bring a proactive, solution-oriented mindset to improve processes and reduce complaint recurrence.

- Are a highly driven individual who goes that extra mile to deliver an outstanding product to the business team and end users/customers.

- Have demonstrated the ability to work in a fast paced and hyper-growth environment using agile methodologies where Customer and Distributor expectations can be changing

This could be the gig for you if you

- Are passionate about bridging clinical expertise with customer-centric service outcomes.

- Want to be part of a start-up culture backed by the strength of two global organizations.

- Thrive in an environment that values agility, innovation, and empathy.





- Believe that every complaint is an opportunity to enhance customer trust.

- Are passionate about bringing truly consumer centric ideas and products into reality and have an attentive ear listen to new ideas.

- Are passionate about leveraging current age digital tools and technologies to transform customer experience.

- Like to work in a culture where everyone can see what others are doing.

- Take help from others when stuck and encourage others when there are setbacks.

- Take full responsibility for your output while thinking wing to wing across the organization; to solve for the customer.

What can make you extra special if you

- Have prior experience handling health claims grievances or Ombudsman/legal cases.

- Possess additional qualifications in Hospital Administration, Health Insurance, or Medical Underwriting.

- Demonstrate a track record of resolving medically complex customer complaints with empathy and fairness.

- Are passionate about improving health claims processes through data-led insights and clinical reasoning.

- Thrive in an environment that values collaboration, compliance, and customer-centric problem solving.

- Have a knack for identifying process gaps and systemic issues, and driving preventive actions with measurable impact.

- Be a team player who is goal orientated, committed, and an advocate and early adopter of change.

- A proven track record working in complex business environments executing and delivering initiatives across multiple domains, stakeholder groups and technology solutions.

📌 Grievance Management Medical Specialist (Mumbai)
🏢 Prudential Health India
📍 Mumbai