To ensure accurate, timely, and compliant processing of claim payments for cashless and reimbursement claims, including payments to network hospitals, policyholders, and other healthcare service providers. The role requires close coordination with Claims, Finance, Insurers, and Network Management teams to facilitate smooth claim settlements and maintain high service standards.
Key Responsibilities
Claims Payment Processing
- Process approved cashless and reimbursement claim payments as per agreed Service Level Agreements (SLAs).
- Verify claim approvals, payment authorizations, and supporting documents before initiating payments.
- Ensure correctness of claim amounts, deductions, co-payments, exclusions, and beneficiary details.
- Process payments to network hospitals, insured members, and healthcare providers through approved payment channels.
Payment Validation & Control
- Perform pre-payment verification to prevent duplicate, excess, or unauthorized payments.
- Validate bank account details, GST information, and payment instructions.
- Identify and escalate discrepancies, exceptions, and suspicious transactions.
Reconciliation & Monitoring
- Reconcile processed payments with claim records and bank statements.
- Track pending, rejected, and failed transactions and ensure timely resolution.
- Maintain accurate payment logs and transaction records.
Stakeholder Coordination
- Coordinate with Claims Processing, Provider Management, Finance, and Insurance Companies for payment-related clarifications.
- Respond to payment queries from hospitals, insurers, and internal stakeholders.
- Follow up on pending approvals and payment releases.
Compliance & Audit
- Ensure adherence to insurer guidelines, TPA operational procedures, and regulatory requirements.
- Maintain complete documentation for audit and compliance reviews.
- Support internal, statutory, and client audits by providing required records and reports.
Reporting & MIS
- Generate daily, weekly, and monthly payment MIS reports.
- Monitor payment turnaround times and identify process improvement opportunities.
- Provide management with payment status reports and exception summaries.
Qualifications
- Bachelor's Degree in Commerce, Finance, Business Administration, Healthcare Administration, or related discipline.
- 1–4 years of experience in Insurance TPA, Health Insurance, Claims Operations, or Finance Operations.
- Experience in health insurance claim settlement processes is preferred.
Pay: ₹20,000.00 - ₹35,000.00 per month
Benefits:
- Cell phone reimbursement
- Provident Fund
Work Location: In person
