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 profe

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