Department: Human Resources
Designation: Claims Executive
Reports To: HR Head
Location: Plot 773-774, Floor 1 to 3, Jan Path, Rani Sati Nagar, Ajmer Road, Jaipur, 302019 (Raj.) India

1. Job Purpose

The Claims Executive will be responsible for managing employee medical insurance claims, coordinating with the Group Medical Coverage (GMC) insurance company and its Third-Party Administrator (TPA), and acting as a bridge between employees and the insurance provider. The role ensures smooth claim processing, timely communication, proper documentation, and effective resolution of employee queries and claim-related issues.

2. Key Responsibilities

A. Employee Medical Insurance & Claims Management

- Handle employee queries related to GMC, medical insurance coverage, hospitalization, reimbursement, and claim settlement.
- Assist employees in understanding insurance benefits, coverage limits, exclusions, eligibility, and claim procedures.
- Guide employees through cashless hospitalization and reimbursement claim processes.
- Collect, verify, and maintain all necessary documents required for medical insurance claims.
- Follow up on pending, rejected, delayed, or partially settled claims and coordinate for their resolution.

B. Coordination with GMC Insurance Company and TPA

- Maintain regular communication and coordination with the GMC insurance company, insurance broker, and TPA.
- Act as the primary point of contact between the company’s employees and the insurance provider.
- Follow up with the insurance company and TPA regarding claim approvals, documentation requirements, settlement status, and outstanding cases.
- Escalate unresolved claims, delays, and grievances to the concerned insurance representatives and ensure timely closure.
- Coordinate for employee additions, deletions, corrections, dependent details, and other policy-related changes.




- Obtain clarification from the insurance company regarding policy terms, coverage, and claim-related discrepancies.

C. Employee Support & Communication

- Serve as a bridge between employees and the insurance company to ensure clear communication and smooth claim processing.
- Provide timely updates to employees regarding claim status, additional document requirements, approvals, and settlement.
- Assist employees and their family members during hospitalization and medical emergencies by coordinating with the insurance provider.
- Address employee grievances professionally and ensure appropriate follow-up until resolution.
- Communicate insurance policy updates, renewal details, and procedural changes to employees.

D. Documentation & Record Maintenance

- Maintain an updated database of employee insurance details, dependents, policy information, and claim records.
- Maintain a tracker for submitted, pending, approved, rejected, and settled claims.
- Ensure proper filing and confidentiality of medical documents, claim forms, and insurance-related correspondence.
- Prepare periodic reports on claim status, pending cases, employee grievances, and settlement trends.
- Ensure all claim documents are submitted accurately and within the timelines prescribed by the insurer.

E. Policy Administration & Renewal

- Assist HR in GMC policy renewal, employee data verification, and policy-related documentation.




- Coordinate with the insurance company to verify employee coverage and resolve discrepancies in policy records.
- Support HR during insurance audits, employee data reconciliation, and policy review meetings.
- Maintain records of insurance premiums, policy schedules, endorsements, and other relevant documents, as assigned.

3. Qualifications & Experience

- Graduate in any discipline; preference for HR, Commerce, Business Administration, or a related field.
- 1–3 years of experience in medical insurance claims, GMC administration, insurance coordination, HR operations, or employee benefits.
- Experience dealing with insurance companies, brokers, hospitals, or TPAs will be an advantage.
- Freshers with good communication and coordination skills may also be considered.

4. Required Skills

- Strong verbal and written communication skills.
- Positive follow-up, coordination, and problem-solving abilities.
- Ability to handle employee grievances with patience and professionalism.
- Knowledge of GMC policies, cashless hospitalization, reimbursement claims, and claim documentation.
- Good record-keeping and reporting skills.
- Proficiency in MS Excel, Word, email, and claim-tracking systems.
- Ability to maintain confidentiality of employee and medical information.

5. Key Performance Indicators (KPIs)

- Timely submission and processing of employee insurance claims.
- Effective follow-up and resolution of pending and rejected claims.
- Response time for employee insurance queries and grievances.
- Accuracy and completeness of claim documentation.
- Timely resolution of discrepancies with the GMC insurance company and TPA.
- Employee satisfaction with insurance-related support.
- Accuracy of employee insurance records and claim status reports.

Pay: ₹10,000.00 - ₹33,000.00 per month

Benefits:

- Cell phone reimbursement
- Provident Fund

Work Location: In person

📌 Claims Executive (Jaipur)
🏢 Miracle Group of Companies
📍 Jaipur