Job Summary
We are seeking a qualified and experienced
medical professional with a strong background in
health insurance claim settlement and
customer service . The ideal candidate will leverage their clinical knowledge to evaluate and process health insurance claims efficiently while ensuring a high level of customer satisfaction. This hybrid role bridges the gap between
medical accuracy ,
regulatory compliance , and
empathetic customer support .
Key Responsibilities
- Medical Review Claims Adjudication:
- Assess and validate medical claims based on clinical documentation and policy coverage.
- Interpret diagnostic reports, treatment plans, and prescriptions to determine claim eligibility.
- Coordinate with internal medical teams to ensure accuracy in claims decision-making.
- Customer Interaction Support:
- Communicate with policyholders, hospitals, and third-party administrators (TPAs) to explain claim decisions in a clear and professional manner.
- Handle escalated or complex customer service issues involving medical claims.
- Offer support and guidance on claim submission processes and documentation requirements.
- Compliance Documentation:
- Ensure all claims are processed in compliance with IRDAI regulations and internal guidelines.
- Maintain accurate records of claim assessments, approvals, denials, and communications.
Required Qualifications
- Education:
- MBBS, BDS, BHMS, BAMS, or equivalent medical degree. Postgraduate qualifications in healthcare or insurance are a plus.
- Experience:
- Minimum 2 5 years of experience in health insurance , especially in claims processing, medical underwriting , or TPA operations .
- Proven track record of customer service experience in a healthcare or insurance setting.
- Skills:
- Strong clinical judgment and attention to detail.
- Excellent communication and interpersonal skills.
- Proficient in claims management systems and MS Office.
- Ability to handle sensitive medical information with confidentiality and professionalism.
HR : Harpreet
Contact: 8839890225
This job is provided by Shine.com
