Key Roles and Responsibilities

1. Claim Intimation and Registration

- Receive claim intimations from clients and assist them throughout the claim process.
- Register claims with the respective insurance companies and TPAs within the prescribed timelines.
- Ensure accurate submission of claim details and obtain claim reference numbers.

2. Claim Documentation and Processing

- Coordinate with clients, hospitals, insurance companies, and TPAs for the collection and submission of required claim documents.
- Verify claim forms, bills, discharge summaries, investigation reports, prescriptions, and other supporting documents.
- Ensure timely submission of documents and compliance with insurer requirements.

3. Claim Follow-up and Settlement

- Regularly follow up with insurance companies and TPAs for claim status, queries, approvals, and settlements.
- Monitor pending claims and ensure timely resolution of outstanding requirements.
- Communicate claim updates and settlement decisions to clients.
- Coordinate for cashless pre-authorisation, enhancement requests, discharge approvals, and reimbursement claims, wherever applicable.

4. Query Management and Claim Resolution

- Respond to insurer queries in coordination with clients and healthcare providers.
- Identify discrepancies in claim assessments, deductions, repudiations, and short settlements.
- Raise reconsideration requests, grievances, and escalations wherever justified.
- Coordinate with insurers for claim review and resolution of disputed deductions.

5. Client Servicing and Support





- Provide end-to-end assistance to clients during the claim process.
- Explain claim procedures, documentation requirements, policy terms, exclusions, and settlement decisions in understandable language.
- Maintain professional communication and ensure a satisfactory client experience.

6. MIS and Reporting

- Maintain accurate records of claim intimations, pending claims, settlements, repudiations, and outstanding queries.
- Prepare regular claim status reports and MIS for clients and management.
- Track turnaround times, pending documentation, and claim settlement performance.
- Maintain proper records of email communications and claim-related documents.

7. Coordination and Compliance

- Coordinate with relationship managers, insurance companies, TPAs, hospitals, and internal departments.
- Ensure adherence to internal processes, insurer guidelines, applicable regulatory requirements, and data confidentiality standards.
- Maintain an organised claim database and ensure timely closure of claim files.
- Required Skills and Competencies Good written and verbal communication skills.
- Solid follow-up, coordination, and negotiation skills.
- Knowledge of health insurance policies, claim procedures, and documentation.
- Ability to analyse claim deductions, queries, and repudiation reasons.
- Proficiency in MS Excel, email communication, and claim management portals.
- Good organisational skills, attention to detail, and problem-solving ability.
- Ability to manage multiple claims and work within defined timelines.

📌 Assistant Manager Claims (Surat)
🏢 Riskaide Insurance Brokers Private
📍 Surat