Key Responsibilities
1. Claim Processing
Review, assess, and process various types of health insurance claims including
reimbursement claims, OPD claims, and pre-authorization requests. Ensure all submitted
documents are complete, valid, and meet the insurer’s requirements before proceeding with
claim evaluation.
2. Medical Adjudication
Analyze medical documents such as prescriptions, invoices, diagnostic reports, and
discharge summaries to evaluate medical necessity. Ensure that treatments and procedures
are clinically justified and fall within the coverage guidelines defined by the insurance
policy.
3. Financial Accuracy
Accurately calculate the admissible claim amount by applying policy-specific conditions
such as room rent capping, sub-limits, co-payments, and proportionate deductions. Ensure
all financial calculations are precise and well-documented to avoid discrepancies.
4. Compliance and Policy Adherence
Ensure that all claim decisions strictly adhere to the policy terms and conditions, insurer
guidelines, and applicable regulatory requirements. Maintain consistency and fairness in
claim adjudication to minimize errors and escalations.
5. Data Management and Documentation
Perform accurate data entry in claim processing systems and maintain detailed records of
all claim decisions including approvals, partial approvals, and denials. Ensure proper
documentation for audit and future reference.
6. Workflow and TAT Management
Efficiently manage high claim volumes by prioritizing high-value and time-sensitive cases.
Ensure all claims are processed within the defined Turnaround Time (TAT) while
maintaining quality and accuracy.
Required Qualifications and Skills
- Doctor of Pharmacy (PharmD) is mandatory.
- Minimum 1 year of experience in healthcare claims processing or medical adjudication.
- Strong understanding of medical terminology, treatments, and clinical documentation.
- Knowledge of health insurance policies, claim processes, and adjudication guidelines.
- Proficiency in MS Office, especially Excel, for data analysis and reporting.
- Strong analytical skills with attention to detail.
- Ability to manage workload efficiently and meet deadlines.
Pay: ₹15,020.02 - ₹38,528.45 per month
Work Location: In person
