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 (Begumpet)
🏢 Kshema
📍 Begumpet