01Overview
Job description Claims processors
Job Purpose
To review and adjudicate inpatient reimbursement claims by validating medical documentation, policy terms, and insurer protocols, ensuring accurate, timely, and compliant claim processing.
Principal Accountabilities
Process inpatient reimbursement claims accurately and within TAT as per insurer and organizational guidelines.
Review and validate medical documents (diagnoses, procedures, discharge summaries) against policy and coding standards.
Escalate complex or out-of-limit cases to the Team Manager/Medical Specialist for timely resolution.
Ensure compliance with regulatory, insurer, and organizational requirements while maintaining audit-ready records.
Coordinate with hospitals for clarifications and support managers in resolving insurer or customer queries.
Reporting Structure:
Reports To: Floor Manager Claims
Major Challenges
Managing high claim volumes while maintaining TAT and accuracy.
Interpreting diverse insurer policies consistently.
Balancing quick turnaround with thorough document scrutiny.
Coordinating with hospitals and internal stakeholders under strict deadlines.
Decisions
Independent: Adjudication of standard pre-authorization cases as per policy terms.
With Approval: Escalations requiring specialist opinion, insurer concurrence, or deviations from package norms.
Interactions
Internal: Claims team, Case Management, CRM team.
External:
Hospitals through Query (for discharge summaries, clarifications, and missing documents).
Insurers (for concurrence and escalations).
Qualifications & Experience
Education: Graduates - B. Pharma
Experience:
Fresher medical graduates can apply.
Prior experience in Pre-Authorization / Claims management in a TPA or HealthTech setup preferred.
Exposure to authorization or reimbursement processes is an added advantage.
Team Lead: 3+ years of experience in the same domain.
Other requirements:
Solid medical knowledge with willingness to work in .
