Role Purpose

To manage end to end health insurance claims (cashless & reimbursement), ensuring timely settlement, fraud control, compliance, and superior customer experience.

Key Responsibilities

1. Claims Processing

Handle cashless and reimbursement claims as per policy terms and IRDAI guidelines

· Verify coverage, eligibility, exclusions, and sub limits

· Assess claim admissibility and compute payable amount

· Ensure TAT adherence for claim processing

2. Cashless Claims Management

· Coordinate with network hospitals and TPAs for pre authorization

· Review medical documents, treatment plans, and estimates

· Approve/deny requests with proper justification

· Handle escalations from hospitals and customers

3. Reimbursement Claims Handling

· Scrutinize bills, discharge summaries, prescriptions, investigation reports

· Detect discrepancies and request additional documents

· Process claims accurately within defined timelines

4. Fraud Detection & Risk Control

· Identify red flags, inflated billing, and fraudulent claims

· Coordinate with investigation teams and field surveyors

· Ensure compliance with internal fraud control mechanisms

5. Customer & Stakeholder Management





· Interact with customers, hospitals, TPAs, and intermediaries

· Resolve queries, complaints, and escalations

· Maintain high customer satisfaction (CSAT)

6. Compliance & Documentation

· Ensure adherence to IRDAI regulations and company SOPs

· Maintain proper documentation and audit trails

· Support internal and external audits

7. MIS & Reporting

· Track claim metrics: TAT, repudiation ratio, loss ratio, leakage

· Prepare periodic reports for management review

Key Skills & Competencies

· Solid understanding of health insurance products & policy wordings

· Knowledge of medical terminology and treatment protocols

· Analytical thinking and attention to detail

· Good communication and negotiation skills

· Ability to handle high volume claims under pressure

· Fraud detection mindset

Requirements

Educational Qualification

Graduate (Medical background preferred: MBBS/BAMS/BHMS/BDS/MBBS/Pharma/Nursing)

Insurance certifications (e.g., III/LOMA) preferred

Experience

5–10 years (Senior Claims Specialist / Team Lead)

Experience in health claims / TPA

📌 Asst manager / Manager Health Claims (India)
🏢 Kshema
📍 India