Key Responsibilities
• 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.
• 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.
• 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.
• 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.
• Positive 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
• 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).
• 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.
• 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.
• 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 (Bengaluru)
🏢 Acko
📍 Bengaluru