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

Key Responsibilities

- 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

- 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

- Reimbursement Claims Handling

- Scrutinize bills, discharge summaries, prescriptions, investigation reports

- Detect discrepancies and request additional documents

- Process claims accurately within defined timelines

- 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

- Customer &

- Stakeholder Management

- Interact with customers,



hospitals, TPAs, and intermediaries

- Resolve queries, complaints, and escalations

- Maintain high customer satisfaction (CSAT)

- Compliance &

- Documentation

- Ensure adherence to IRDAI regulations and company SOPs

- Maintain proper documentation and audit trails

- Support internal and external audits

- 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 (Secunderabad)
🏢 Kshema General Insurance
📍 Secunderabad