Job Description:
Approvals & Closures
Managing repudiation and buffer approvals.
Reopening and processing closed claims in case of incorrect repudiation, as per approval hierarchy.
Ensuring closure of eligible claims through API integration wherever applicable
Process Corrections & Communication
Identifying and correcting wrong processing at RFP or medical stage.
Sending clarification and endorsement-related mails to IC when required.
Coordinating with CRM teams and branches for payment status updates and claim-related communication.
Grievance & Escalation Handling
Handling grievance claims and escalation mails referred to IC regarding deductions or repudiated claims.
Coordinating with internal stakeholders for resolution within defined timelines.
Provider
Managing excluded hospital pop-ups and coordinating with provider team based on processing doctors inputs.
API error related to provider – coordinate with IC
BEM
Co ordination with Enrolment Team
APJ / RSA Integration & Error Resolution
Addressing APJ integration errors including:
Invalid hospital ID / employee ID
Payee ID updating
Incorrect ICD coding
Missing or compressed documents
Policy service data errors
Denial reason not updated
Approved amount mismatch etc.
Following up on RSA claim numbers and ensuring system accuracy.