Walk-in || Claims Manager

Key Responsibilities

• Review and evaluate medical claim documents to determine claim admissibility.
• Analyze medical records, treatment details, and hospitalization documents.
• Interpret policy wordings, terms & conditions, exclusions, and coverage provisions for claim settlement.
• Process health insurance claims in compliance with regulatory and company guidelines.
• Ensure adherence to defined Turnaround Time (TAT) and quality standards.
• Conduct quality reviews of processed claims and maintain accuracy.
• Handle customer grievances, claim escalations, and query resolutions.
• Identify suspicious or fraudulent claims and escalate cases as per the defined process.
• Maintain appropriate documentation and records related to claim decisions.

Required Skills & Qualifications

• Strong clinical knowledge of medical treatments, procedures, and hospitalization practices.
• Understanding of treatment protocols and diagnostic protocols.
• Knowledge of health insurance claim adjudication and policy interpretation.
• Good analytical, decision-making, and problem-solving skills.
• Strong attention to detail and quality orientation.
• Good communication and stakeholder management skills.

Preferred Candidate Profile

• Experience in Health Insurance Companies or Third-Party Administrators (TPA).
• Background in Nursing, Pharmacy, Life Sciences, Allied Health Sciences, BAMS, BHMS, MBBS, or equivalent healthcare disciplines.
• Prior experience in medical claims processing, claims adjudication, or utilization management is preferred.