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. Eligibili

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