Key Roles & Responsibilities Insurance Claim Operations Manage 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 Strong 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 Positive 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