Key Responsibilities

1. Claim Processing

Review, assess, and process various types of health insurance claims including reimbursement claims, OPD claims, and pre-authorization requests. Ensure all submitted documents are complete, valid, and meet the insurer’s requirements before proceeding with claim evaluation.
1. Medical Adjudication

Analyze medical documents such as prescriptions, invoices, diagnostic reports, and discharge summaries to evaluate medical necessity. Ensure that treatments and procedures are clinically justified and fall within the coverage guidelines defined by the insurance policy.
1. Financial Accuracy

Accurately calculate the admissible claim amount by applying policy-specific conditions such as room rent capping, sub-limits, co-payments, and proportionate deductions. Ensure all financial calculations are accurate and well-documented to avoid discrepancies.
1. Compliance and Policy Adherence

Ensure that all claim decisions strictly adhere to the policy terms and conditions, insurer guidelines, and applicable regulatory requirements. Maintain consistency and fairness in claim adjudication to minimize errors and escalations.
1. Data Management and Documentation





Perform accurate data entry in claim processing systems and maintain detailed records of all claim decisions including approvals, partial approvals, and denials. Ensure proper documentation for audit and future reference.
1. Workflow and TAT Management

Efficiently manage high claim volumes by prioritizing high-value and time-sensitive cases. Ensure all claims are processed within the defined Turnaround Time (TAT) while maintaining quality and accuracy.

Required Qualifications and Skills

- Doctor of Pharmacy (PharmD) is mandatory.
- Minimum 1 year of experience in healthcare claims processing or medical adjudication.
- Strong understanding of medical terminology, treatments, and clinical documentation.
- Knowledge of health insurance policies, claim processes, and adjudication guidelines.
- Proficiency in MS Office, especially Excel, for data analysis and reporting.
- Strong analytical skills with attention to detail.
- Ability to manage workload efficiently and meet deadlines.

Pay: ₹15,020.02 - ₹38,528.45 per month

Application Question(s)

- What is your Current CTC ?
- What is your expected CTC ?
- Notice Period ?

Work Location: In person

📌 Claims Executive (Immediate Joiner) (Bengaluru)
🏢 Connect And Heal Primary Care Private
📍 Bengaluru