Grievance Management Medical Specialist

Prudential (UK) in partnership with the HCL group plans to set-up a standalone Indian health insurance company to address the growing healthcare needs of the Indian consumer.

This joint venture will combine Prudential's global expertise in insurance and financial services with HCL Groups experience in technology and healthcare solutions.

Prudential, with its longstanding presence in India, already operates two leading businesses in life insurance and asset management with the ICICI Group. Prudential was also the proud sponsor of the 1983 Cricket World Cup, Indias first World Cup Victory!

Prudential Health India is a Zero to One team undertaking a no-legacy, greenfield health insurance deployment in India, building journeys that truly empathize with the customer and offer a differentiated experience.

To partner with us in this mission, we are looking for a talented Grievance Management Medical Specialist to join our Customer Service team in Mumbai.

Your typical week might include the following:

• Reviewing and analyzing health-claims-related grievances to ensure accurate, fair, and timely resolution within defined regulatory timelines.
• Conducting detailed medical assessment of claim files, discharge summaries, investigation reports, and clinical notes to validate decisions and ensure fairness.
• Collaborating closely with Claims, Underwriting, Legal, and TPA teams to provide clinical clarity and assist in resolving complex health-related complaints.
• Ensuring grievances received through regulatory and public portals (e.g., Bima Bharosa, IGMS, PG Portal) are closed within prescribed IRDAI timelines.
• Preparing and supporting medical summaries and responses for Ombudsman and litigation cases.
• Identifying recurring medical issues, performing root cause analysis (RCA), and recommending corrective and preventive actions.
• Acting as the voice of the customer, ensuring empathetic, transparent, and accurate communication of medical decisions.
• Contributing to knowledge base creation by documenting medical FAQs, precedents, and claim adjudication guidelines.
• Partnering in process improvement initiatives aimed at enhancing medical accuracy and reducing repeat grievances.
• Supporting service recovery initiatives to transform complaints into opportunities for customer delight and retention.

You could be the right candidate if you:

• Are a qualified medical professional – MBBS / BAMS / BHMS / BDS (mandatory).
• Have 4–8 years of experience in health insurance, TPA operations, hospital administration, or medical audit.
• Possess strong knowledge of IRDAI regulations, claims assessment processes, and health insurance guidelines.
• Demonstrate the ability to balance clinical accuracy with customer empathy.
• Are comfortable reviewing complex medical documentation and making sound, evidence-based judgments.
• Can collaborate effectively across functions like Claims, Underwriting. Legal, Compliance, and Customer Service.
• Are detail-oriented, disciplined, and capable of working within defined TATs and regulatory norms.
• Have strong written and verbal communication skills to explain complex medical matters in simple, customer-friendly language.
• Bring a proactive, solution-oriented mindset to improve processes and reduce complaint recurrence.
• Are a highly driven individual who goes that extra mile to deliver an outstanding product to the business team and end users/customers.
• Have demonstrated the ability to work in a fast paced and hyper-growth environment using agile methodologies where Customer and Distributor expectations can be changing

This could be the gig for you if you

• Are passionate about bridging clinical expertise with customer-centric service outcomes.
• Want to be part of a start-up culture backed by the strength of two global organizations.
• Thrive in an environment that values agility, innovation, and empathy.
• Believe that every complaint is an opportunity to enhance customer trust.
• Are passionate about bringing truly consumer centric ideas and products into reality and have an attentive ear listen to new ideas.
• Are passionate about leveraging new age digital tools and technologies to transform customer experience.
• Like to work in a culture where everyone can see what others are doing.
• Take help from others when stuck and encourage others when there are setbacks.
• Take full responsibility for your output while thinking wing to wing across the organization; to solve for the customer.

What can make you extra special if you

• Have prior experience handling health claims grievances or Ombudsman/legal cases.
• Possess additional qualifications in Hospital Administration, Health Insurance, or Medical Underwriting.
• Demonstrate a track record of resolving medically complex customer complaints with empathy and fairness.
• Are passionate about improving health claims processes through data-led insights and clinical reasoning.
• Thrive in an environment that values collaboration, compliance, and customer-centric problem solving.
• Have a knack for identifying process gaps and systemic issues, and driving preventive actions with measurable impact.
• Be a team player who is goal orientated, committed, and an advocate and early adopter of change.
• A proven track record working in complex business environments executing and delivering initiatives across multiple domains, stakeholder groups and technology solutions.

We are keen to listen to your story; doesn’t matter if you tell these stories with a sigh or with excitement. We respect both versions.