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 & S

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