Health Claims | B. Pharma

Key Responsibilities:

• Review and assess health insurance claims as per policy terms and medical guidelines.
• Analyze medical records, prescriptions, diagnostic reports, and hospitalization documents.
• Verify claim admissibility and identify discrepancies, inconsistencies, or potential fraud.
• Coordinate with hospitals, policyholders, TPAs, and internal stakeholders for claim processing.
• Ensure timely settlement or repudiation of claims within defined TATs.
• Maintain accurate claim documentation and update claim management systems.
• Provide medical opinion and interpretation on treatment protocols, medications, and procedures.

Eligibility:

• B. Pharma degree (mandatory).
• 0-3 years of experience in health insurance claims, TPA, hospital operations, or medical underwriting preferred.
• Good understanding of medical terminology, diseases, treatments, and pharmaceuticals.
• Strong analytical, communication, and documentation skills.
• Proficiency in MS Office and claim processing systems.

Desired Skills:

• Attention to detail and accuracy.
• Ability to interpret clinical and policy-related information.
• Customer-centric approach with problem-solving mindset.
• Ability to work in a fast-paced claims environment.