- Experience
- 1+ yrs
- Location
- Bengaluru, Pune, Maharashtra, India, Gurgaon, Haryana, India, Delhi, India, Mumbai, Maharashtra, India
Required skills
- health insurance claims assessment
- claims auditing
- quality control
Nice to have
- medical claim scrutiny
- medical claim validation
About the role
Job Purpose
To ensure the accuracy, quality and compliance of health insurance claims processed by the TPA team. The role involves
reviewing claim assessments, validating medical documentation, identifying discrepancies and ensuring adherence to
company policies and established claims processing guidelines.
Key Roles & Responsibilities
Conduct quality checks and audits of processed health insurance claims.
Review claim documents, medical reports, bills and supporting records for accuracy and completeness.
Ensure claims are processed in accordance with policy terms, medical guidelines and TPA protocols.
Identify errors, discrepancies and deviations in claim processing and recommend corrective actions.
Validate the medical justification for treatments, procedures and hospitalization expenses.
Ensure compliance with internal quality standards and applicable regulatory guidelines.
Coordinate with claims processing and medical teams to resolve discrepancies.
Prepare quality audit reports and maintain records of observations and corrective actions.
Identify recurring errors and suggest process improvements to enhance claim quality and efficiency.
Candidate Requirements
Educational Qualification
BAMS / BHMS / MBBS is mandatory.
Only candidates with the specified medical qualifications will be considered.
Industry & Experience
Relevant experience in the Health Insurance or TPA industry is mandatory.
Exposure to health insurance claims assessment, auditing or quality control is preferred.
Hands-on experience in medical claim scrutiny and validation will be an advantage.
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