Key Responsibilities

1. File Review & Assessment

- Review all open claim files assigned (cashless & reimbursement).
- Verify completeness of documentation (pre-authorization forms, discharge summaries, bills, prescriptions, investigation reports, etc.).
- Check for missing or inconsistent information and initiate follow-ups with hospitals, TPAs, or claimants.
- Evaluate medical necessity of treatments against standard guidelines and policy coverage.
- Identify any non-payable items, exclusions, or excess billing.

1. Policy & Compliance Verification

- Ensure all claims are adjudicated as per policy wordings, benefit plans, exclusions, and sub-limits (if applicable).
- Maintain compliance with IRDAI regulations and company SOPs.
- Escalate potential cases of fraud, abuse, or misrepresentation to the investigation team.

1. Coordination & Communication

- Liaise with medical panel doctors, TPAs, hospital coordinators, and internal claims teams for clarifications.
- Provide accurate updates on claim status and pending requirements.
- Ensure professional and clear communication with all stakeholders.

1. Quality & Process Improvement

- Track claim pendency, turnaround time (TAT), and provide periodic reports on open files.
- Contribute to process improvements to minimize open file pendency.
- Assist in root cause analysis for delays and recommend corrective measures.

Key Skills & Competencies

- Strong knowledge of health insurance policies, medical terminology, and hospital billing practices.
- Ability to interpret policy wordings, exclusions, and benefit clauses.
- Analytical thinking with attention to detail.
- Good communication and coordination skills.
- Proficiency in MS Office and claims management systems.

Qualifications & Experience

- Graduate MBBS,BAMS,BHMS,BDS.




- 1–4 years’ experience in health insurance claims adjudication, TPA operations, or hospital billing.

Performance Indicators (KPIs)

- Timely closure of open claims within defined TAT.
- Accuracy in claim review and adjudication.
- Reduction in repeated queries or rework.
- Compliance adherence (regulatory and internal SOPs).
- Quality of documentation and escalation.

Key Responsibilities

1. Claims Processing & Adjudication

- Receive and validate OPD claims submitted by policyholders (consultation, diagnostics, pharmacy bills, preventive health check-ups, etc.).
- Check claim forms, prescriptions, invoices, and supporting medical documents for accuracy and completeness.
- Verify eligibility, coverage limits, exclusions, and waiting periods under the policy.
- Identify non-payable expenses and process the payable amount as per policy terms.
- Ensure claims are settled within the defined turnaround time (TAT).

1. Medical & Financial Scrutiny

- Validate medical necessity for consultations, diagnostics, and prescribed medications.
- Cross-check billing and pricing norms against market standards and internal guidelines.
- Flag suspicious or inflated claims for investigation.

1. Coordination & Communication

- Liaise with insured members, hospitals, diagnostic centers, and pharmacies for clarifications or missing documents.
- Escalate complex cases to senior medical officers or investigation team where required.
- Provide explicit and professional communication to customers regarding claim approvals, deductions, or rejections.

1. Compliance & Quality Assurance

- Adhere to IRDAI regulations and company SOPs in claim adjudication.
- Maintain proper documentation and audit trails for every claim.

Participate in internal audits and quality checks to ensure process compliance.

📌 Sr Associate - Health claims (CL&MR) (Bengaluru)
🏢 Acko
📍 Bengaluru