Executive - SPOC

Job Description:

• Approvals & Closures
  - Managing repudiation and buffer approvals.
  - Reopening and processing closed claims in case of incorrect repudiation, as per approval hierarchy.
  - Ensuring closure of eligible claims through API integration wherever applicable
• Process Corrections & Communication
  - Identifying and correcting wrong processing at RFP or medical stage.
  - Sending clarification and endorsement-related mails to IC when required.
  - Coordinating with CRM teams and branches for payment status updates and claim-related communication.
• Grievance & Escalation Handling
  - Handling grievance claims and escalation mails referred to IC regarding deductions or repudiated claims.
  - Coordinating with internal stakeholders for resolution within defined timelines.
• Provider
  - Managing excluded hospital pop-ups and coordinating with provider team based on processing doctors inputs.
  - API error related to provider – coordinate with IC
• BEM
• Co ordination with Enrolment Team
• APJ / RSA Integration & Error Resolution
  - Addressing APJ integration errors including:
  - Invalid hospital ID / employee ID
  - Payee ID updating
  - Incorrect ICD coding
  - Missing or compressed documents
  - Policy service data errors
  - Denial reason not updated
  - Approved amount mismatch etc.
  - Following up on RSA claim numbers and ensuring system accuracy.