01Overview
Role & responsibilities
1. Cashless Claim Processing
Review and process cashless health insurance claims received from hospitals/TPAs/insurers.
Scrutinize pre-authorization requests, medical documents, treatment details, diagnosis, and proposed treatment plans.
Verify policy coverage, eligibility, exclusions, waiting periods, and applicable terms and conditions.
Assess the medical necessity and appropriateness of the proposed treatment.
Review hospital estimates, investigation reports, prescriptions, clinical notes, and other relevant documents.
Process approvals, queries, enhancements, denials, and final authorizations within defined TAT.
Coordinate with hospitals, insurance companies, TPAs, doctors, and internal teams for missing information or clarification.
Ensure appropriate medical and non-medical deductions are applied as per policy guidelines.
Maintain accuracy and quality while meeting defined productivity and TAT targets.
Escalate complex, high-value, doubtful, or potentially fraudulent cases to the appropriate authority.
2. Reimbursement Claim Processing
Review reimbursement claims submitted by insured members after hospitalization/treatment.
Verify claim forms, bills, discharge summaries, prescriptions, investigation reports, medical records, and other supporting documents.
Validate hospitalization details, diagnosis, treatment, duration of stay, and expenses against policy coverage.
Assess admissibility of medical expenses as per policy terms and applicable guidelines.
Identify non-payable, inadmissible, duplicate, unrelated, or unsupported expenses.
Review pre- and post-hospitalization expenses wherever applicable.
Raise appropriate queries for incomplete, inconsistent, or insufficient documentation.
Process payable, partially payable, repudiated, or non-payable claims based on applicable policy terms.
Ensure proper documentation and justification for claim decisions.
Maintain defined TAT, accuracy, quality, and productivity standards.
3. Medical Claim Assessment
Analyze clinical information, diagnosis, treatment protocols, investigations, and hospitalization records.
Determine whether the treatment and hospitalization are medically justified based on available records.
Identify discrepancies between diagnosis, treatment, documentation, and claimed expenses.
Provide appropriate medical opinions for complex or doubtful cases.
Identify potential misrepresentation, non-disclosure, fraud, abuse, and policy violations.
Escalate cases requiring specialist review or further investigation.
4. Quality & Compliance
Ensure all claims are processed strictly as per policy terms, SOPs, client guidelines, and regulatory requirements.
Maintain high accuracy and quality standards while processing claims.
Ensure complete and appropriate documentation of every claim decision.
Follow defined escalation matrix and claim-processing workflows.
Maintain confidentiality and security of insured/patient information.
Participate in quality audits and implement corrective actions for identified errors.
5. Productivity & TAT Management
Achieve assigned daily/monthly claim-processing targets without compromising quality.
Ensure timely closure of cases within defined TAT.
Monitor pending, query, enhancement, and overdue cases.
Prioritize cases based on TAT, urgency, claim type, and client requirements.
Provide timely updates on cases approaching or exceeding TAT.
Maintain individual productivity and contribute to overall team performance.
Preferred candidate profile
TPA or health insurance background .
