Job Title: Medical Claims Executive / Medical Claims Officer
Department: Health Insurance Claims
Qualification: BAMS / BHMS (Registered )
Experience: 0–3 Years (Freshers may also apply)
Location: Delhi
Reporting To: Claims Manager
Job Summary
The Medical Claims Executive will be responsible for reviewing and assessing health insurance claims, evaluating medical records, ensuring compliance with policy terms, and providing medical opinions for claim adjudication. The role requires medical knowledge to assess treatments, diagnoses, hospitalization records, and claim eligibility.
Key Responsibilities
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· Review and evaluate health insurance claims and medical documents.
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· Analyze hospitalization records, discharge summaries, prescriptions, investigation reports, and treatment details.
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· Verify the medical necessity and appropriateness of treatments and procedures.
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· Assess claim admissibility as per policy terms and conditions.
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· Identify discrepancies, fraud indicators, and non-disclosures in claim documents.
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· Provide medical opinions and recommendations for claim approval, rejection, or further investigation.
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· Coordinate with hospitals, policyholders, TPAs, and internal teams for claim clarification.
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· Review pre-authorization and reimbursement claims.
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· Ensure compliance with IRDAI guidelines and company policies.
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· Maintain accurate claim records and prepare reports as required.
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· Support audits and quality checks related to claim processing.
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Required Qualifications
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· MBBS / BAMS / BHMS degree from a recognized institution.
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· Valid medical registration.
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· Basic understanding of health insurance and claims processes.
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· Ability to interpret medical records and treatment protocols.
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· Strong analytical and decision-making skills.
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· Good communication and documentation abilities.
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· Proficiency in MS Office (Excel, Word, Outlook).
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Preferred Skills
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· Experience in Health Insurance, TPA, Hospital Administration, or Medical Auditing.
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· Knowledge of ICD coding, medical terminology, and claim adjudication processes.
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· Familiarity with cashless and reimbursement claim procedures.
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Key Performance Indicators (KPIs)
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· Accuracy of claim assessments.
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· Turnaround Time (TAT) for claim processing.
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· Quality and consistency of medical opinions.
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· Compliance with regulatory and internal guidelines.
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· Reduction in claim leakage and fraud detection.
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Salary Range
As per qualification, experience, and company standards.
Employment Type
Full-Time
Working Days: Monday to Saturday (as applicable)
Industry: Health Insurance / TPA / Insurance Broking / Healthcare Services.
Pay: ₹40,000.00 - ₹60,000.00 per month
Benefits:
Application Question(s):
- BAMS / BHMS (Registered )
- Must have any Doctor Degree
Work Location: In person
