Sr. Associate - OPD Claims | Claims Processing and Customer Calling

Role Overview

We are looking for a Claim Handler - OPD Claims, responsible for reviewing, evaluating, and processing insurance claims as per company policies and regulatory guidelines. The role involves medical document review, claim assessment, customer coordination, and claim-related calling while ensuring accuracy, quality, and timely resolution.

Key Responsibilities

• Evaluate, review, and process claims in accordance with company policies, procedures, productivity, and quality standards.
• Examine medical documents and assess claim admissibility based on policy terms and conditions.
• Review medical claims and verify information for accuracy and completeness.
• Coordinate with customers over calls to explain policy terms & conditions, claim details, claim status, and documentation requirements.
• Handle customer queries related to claims and provide timely updates/resolutions.
• Deliver excellent customer service by addressing policyholder concerns professionally.
• Identify discrepancies in claims and coordinate for corrections or additional information.
• Examine claims for potential fraud indicators and conduct investigations wherever required.
• Gather additional information/documents to determine the validity of claims.
• Ensure compliance with company policies, processes, and regulatory requirements.
• Maintain productivity and quality standards as per defined expectations.
• Process claim payments accurately as per approvals and guidelines.
• Adapt to cross-training opportunities and manage multiple claim-related activities.
• Perform other claim-related tasks as required.

Required Skills & Competencies

• Good communication skills in English and Hindi (mandatory).
• Comfortable with customer coordination and customer calling.
• Strong customer service skills.
• Good medical knowledge and understanding of medical terminology.
• Basic understanding of insurance claims process (preferred).
• Basic knowledge of IRDAI guidelines will be an added advantage.
• Strong analytical and problem-solving skills.
• Attention to detail and ability to verify documents accurately.
• Ability to multitask and adapt to process requirements.
• Basic knowledge of MS Office (Excel, Word, Outlook).

Qualification (Mandatory):

• Candidate must hold a medical degree/qualification such as:
• B.Pharm
• Pharm D
• B.Sc Nursing
• BDS
• BHMS
• BAMS
• Any other relevant medical/healthcare qualification
• Freshers can apply.
• Candidates with prior experience in health insurance claims, medical claims processing, or healthcare operations will be preferred.

Work Details

• Work Mode: Work from Office (WFO)
• Working Days: 6 days working
• Weekly Off: 1 rotational week off
• Shift Timings: General shift timings
• Transport Facility: Not provided
• Languages Required: English and Hindi mandatory
• Candidate should be open for customer calling and customer coordination as part of the role.