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 qualified

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