● Audit claim files, check claim papers according to disease, examine medical reports, match prescriptions and in case of deficiencies of documents answer queries raised by insurance/TPA. ● Provide services to all business requirements and ensure optimal handling of all claims and investigate all issues and provide training for all business units. ● Responsible for accurate claim assessment and speedy claim decisions within the stipulated IRDA guidelines. ● Supervise processing of all health claims billing issues. ● To determine if the amount of the claims requested fits into SOC (Schedule of Charges) or PPN criteria. ● Scrutiny of files to determine if the claims do really qualify to be reimbursed or to be settled. ● Maintain knowledge of all appropriate medical insurance coverage laws in the local, state and federal jurisdiction area when reviewing claims submissions ● Provide medical assessment support /opinions to other team members ● Monitoring claim processing activities, performance management, and production standards and quality of results ● Analyzes data for bill presentation based on requirements and reviews claims for quality ● Manage the day to day operations of the assigned Claims Department to accurately and timely process members’ medical claims. ● Visits to hospitals may be required to liaison with hospital staff and to monitor the claims processing activities. ● To verify if all the document submission has been completed in time by the processing team. ● MIS submission to TPA – Head.

BAMS/BHMS/BUMS Must have 4-5 years’ experience in TPA/Insurance/Hospitals. Must have effective communication skills. Candidates must have sound knowledge about claims processing in hospitals and TPA. Should have good clinical knowledge and medical admissibility of claims Excellent knowledge about Insurance policy terms and conditions Team handling experience Analytics and problem-solving skills