Job Summary
We are looking for a detail-oriented medical professional to join our team as a Claims Assessor, responsible for evaluating health insurance claims. The role involves reviewing medical records, assessing claim admissibility in accordance with policy terms and medical evidence, identifying discrepancies or fraud indicators, and ensuring fair, accurate, and timely claim decisions while maintaining the highest standards of medical ethics and confidentiality.
Key Responsibilities
- Assess health claims by reviewing medical records, hospital documents, investigation reports, and policy information.
- Evaluate medical evidence to determine claim admissibility in accordance with policy terms and underwriting guidelines.
- Identify inconsistencies, non-disclosures, fraud indicators, and medical red flags during claim assessment.
- Provide medical opinions and recommendations for claim acceptance, repudiation, or further investigation.
- Coordinate with internal claims teams, investigators, underwriters, and clients for clarification or additional documentation.
- Review cause of death, hospitalization records, diagnostic reports, and treatment history where applicable.
- Maintain accurate documentation of assessment findings and recommendations within internal systems.
- Prepare medical assessment reports within defined turnaround times.
- Ensure compliance with IRDAI regulations, insurer guidelines, and company policies.
- Provide guidance and support to junior claims staff on medical aspects of claim evaluation.
- Participate in quality audits and continuous process improvement initiatives.
- Maintain strict confidentiality of customer medical information and company data.
Required Skills & Competencies
- Strong knowledge of medical terminology, disease processes, diagnostics, and treatment protocols.
- Good understanding of life insurance claims assessment and underwriting principles.
- Excellent analytical and clinical decision-making skills.
- Ability to interpret complex medical records and laboratory reports.
- Strong attention to detail with high documentation accuracy.
- Good written and verbal communication skills.
- Proficiency in MS Office, particularly Excel, Word, and email communication.
- Ability to manage multiple cases while meeting turnaround timelines.
- High ethical standards and professional integrity.
Educational Qualification
- MBBS (Preferred)
- BAMS / BHMS / BDS may also be considered based on relevant life insurance claims experience.
- Fellowship or certification in Insurance Medicine, Claims Assessment, or Underwriting will be an added advantage.
Experience Required
- 1–5 years of experience in life insurance claims assessment, underwriting, insurance medicine, or clinical practice.
- Experience in assessing death claims, critical illness claims, or health-related life insurance claims will be preferred.
- Fresh MBBS graduates with strong analytical skills and an interest in insurance medicine may also be considered.
Salary
- As per industry standards and candidate experience.
Working Days & Timings
- Flexible work timings with 9-hour shifts.
- Candidates should be comfortable working on weekends and government holidays, depending on business requirements and operational needs.
Additional Notes
- Candidates should be comfortable working in a paperless, work-from-home environment.
- Immediate joiners may be given preference.
- Candidates should have access to a stable internet connection and a suitable work-from-home setup.
- Timely response and adherence to defined turnaround times (TATs) are essential.
- Prior experience with life insurance companies, TPAs, or insurance BPO/KPO organizations will be an added advantage.
Pay: From ₹23,000.00 per month
Benefits:
- Flexible schedule
- Health insurance
- Work from home
Work Location: Hybrid remote in Mumbai, Maharashtra (Mumbai)
