Key Roles & ResponsibilitiesInsurance 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 HandlingExtensive handling of TPA and insurer portals, including:Claim intimation and registrationUploading and verification of documentsRaising and responding to insurer/TPA queriesTracking approvals, rejections, and settlementsFinal claim closure and documentationMedical Scrutiny & EvaluationPerform detailed medical scrutiny of:Hospital bills, discharge summaries, and case sheetsInvestigation and diagnostic reportsPharmacy bills, consumables, ICU/ward chargesOperative notes and treatment recordsAssess:Medical necessity and diagnosis validationTreatment protocol appropriatenessICU vs ward justificationLength of stay and cost reasonablenessPolicy Compliance & Risk IdentificationIdentify and evaluate:Pre-Existing Diseases (PED)Non-disclosure or misrepresentationPolicy exclusions and breachesInconsistencies in clinical and billing documentsSupport fraud detection through:Clinical correlationBilling pattern analysisVerification of medical and financial documentsCoordination & CommunicationCoordinate with:Hospitals, treating doctors, and internal clinical teamsTPAs, insurance companies, investigatorsInsured members and patient relativesObtain clarifications, additional documents, and medical justifications as required.Settlement, MIS & ComplianceCalculate 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 & SkillsEducational QualificationGraduate in any disciplinePreferred: Healthcare Administration / Medical / Insurance-related backgroundExperienceMinimum 2 years of experience in:Health insurance claimsTPA / Hospital insurance desk / Insurance company operationsTechnical & Functional SkillsStrong knowledge of:Health insurance policies & claim workflowsIRDAI regulations and insurer guidelinesCashless and reimbursement claim processesHands-on experience with insurer and TPA portalsGood understanding of medical terminology and hospital billingProficiency in MS Excel, MIS reporting, and documentationSoft SkillsStrong coordination and communication skillsHigh attention to detail and analytical thinkingAbility to manage multiple claims and deadlinesEthical, process-oriented, and compliance-driven approach

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