Role & Responsibilities:
• Check medical admissibility of claims by validating diagnosis and treatment details
• Scrutinize claims in accordance with insurance policy terms and conditions
• Interpret ICD coding and assess co-pay, non-medical expenses, room rent capping, and tariff applicability
• Differentiate between open billing and package billing
• Understand and process PA and RI claims as per defined guidelines
• Verify completeness of documents and raise IRs in case of insufficiency
• Approve or deny claims within stipulated TAT
• Handle escalations and respond to emails and internal queries
Qualification:
• MBBS or equivalent medical qualification preferred
• Graduates with relevant claims or healthcare domain knowledge may be considered
Experience:
• 0–3 years of experience in medical claims processing, insurance, TPA, or healthcare operations
Skills:
• Medical Claims Processing & Adjudication
• ICD Coding Interpretation
• Analytical & Decision-Making Skills
• Basic Computer & Typing Skills
• Good Communication & Email Handling Skills
• Attention to Detail & Time Management
About the Company:
• The organization operates in the healthcare insurance and TPA domain, providing end-to-end medical claims management services with a strong focus on accuracy, compliance, and timely settlements.