Job highlights

- Graduate (Medical background preferred: MBBS / BAMS / BHMS / BDS / MBBS / Pharma / Nursing)
- Insurance certifications (e.g.,III/LOMA) preferred
- . Valuable communication and negotiation skills
- Experience
- Experience in health claims / TPA

Job_Description":" 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

1. 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

1. Reimbursement Claims Handling

Scrutinize bills, discharge summaries, prescriptions, investigation reports Detect discrepancies and request additional documents

Process claims accurately within defined timelines

1. 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

1.



Customer & Stakeholder Management

Interact with customers, hospitals, TPAs, and intermediaries Resolve queries, complaints, and escalations

Maintain high customer satisfaction (CSAT)

1. Compliance & Documentation

Ensure adherence to IRDAI regulations and company SOPs Maintain proper documentation and audit trails

Support internal and external audits

1. MIS & Reporting

Track claim metrics: TAT, repudiation ratio, loss ratio, leakage Prepare periodic reports for management review

Key Skills & Competencies

Strong 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

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This job posting has been aggregated from external source. Role details, content, and availability are subject to change. Applicants are advised to confirm the latest information directly on the company website before applying.

📌 Asst manager / Manager Health Claims (Hyderabad)
🏢 Kshema General Insurance
📍 Hyderabad