Role & responsibilities

To process and manage health insurance claims by verifying documents, coordinating with hospitals/TPAs, and ensuring accurate and timely claim settlement in line with policy terms, internal guidelines and regulations.

Key Responsibilities

- Register and process health insurance claims (cashless and reimbursement) as per defined workflows and SLAs.
- Verify policy details, coverage, waiting periods, exclusions and eligibility before approving or recommending payment.
- Check completeness and accuracy of claim documents (hospital bills, discharge summary, investigation reports, prescriptions, KYC).
- Coordinate with hospitals, TPAs, internal teams and customers to obtain clarifications or missing documents and resolve discrepancies.
- Scrutinize medical records for reasonableness of treatment, length of stay and adherence to policy conditions; flag doubtful or potentially fraudulent claims for further review.
- Prepare claim assessment notes and recommendations for approvals, rejections or queries as per authority limits and guidelines.
- Update claims management system with accurate data, status, remarks and financials at each stage of claim processing.




- Respond to customer and corporate client queries regarding claim status, documentation requirements and settlement details.
- Ensure adherence to company policies, IRDAI guidelines and data privacy norms in all claims handling activities.
- Support audits, MIS and reporting by maintaining proper records and providing required information on time.
- Qualifications & Experience

- Graduate in any discipline; preference for B.Sc / B.Pharm / Nursing / Life Sciences or healthcare background.
- 4-8 years of experience in health insurance claims / TPA / medical billing; freshers with solid aptitude in healthcare/insurance can also be considered.

Skills & Competencies

- Good understanding (or willingness to learn) of health insurance concepts, hospital billing and basic medical terminology.
- Strong attention to detail, documentation and analytical ability.
- Effective communication skills for interacting with hospitals, TPAs, customers and internal teams.
- Proficiency in MS Office and claims/TPA software.
- Customercentric attitude, integrity and ability to work under time pressure and high volumes.

For more information please call Gopakumar@(phone hidden)

📌 Senior Manager- Health Claims Provider- Health Insurance-10.5 lacs (Ernakulam)
🏢 Wego Consultants
📍 Ernakulam