A Healthcare Claims Manager oversees the operational, financial, and regulatory processes involved in evaluating, processing, and settling medical claims. They sit at the intersection of clinical care, financial administration, and regulatory compliance, working for health insurance companies (payers), Third Party Administrators (TPAs), or healthcare systems (providers)
Core Responsibilities
- Claims Adjudication & Lifecycle Management: Oversee the end-to-end processing of inpatient, outpatient, dental, and specialty claims, ensuring adherence to coverage terms, tariffs, and medical necessity.
- Denial & Grievance Oversight: Manage escalated, high-value, or disputed claims. Review complex medical files to determine accurate coverage or rejection grounds.
- Regulatory & Policy Compliance: Ensure all claim workflows comply with state and national healthcare regulations (such as HIPAA, ACA, IRDAI, or CMS standards).
- Fraud, Waste, & Abuse (FWA) Prevention: Monitor billing patterns, audit claims data, and catch over-billing, unbundling, or fraudulent submissions before payout.
- Team Leadership & TAT Optimization: Direct teams of claims adjusters, medical reviewers, and billing specialists to maintain strict Turnaround Times (TAT) and high "clean claim" submission rates.
- System & Vendor Management: Leverage modern claims adjudication systems (e.g., Facets, QNXT, Xcelys) and RCM platforms to automate workflows and maintain data accuracy.
Pay: ₹900,000.00 - ₹1,100,000.00 per year
Work Location: In person
