Posted:10 hours ago|
Platform:
Work from Office
Full Time
Position Overview
Looking to leverage your medical expertise in a dynamic insurance environment As a Claims Associate Medical, you will play a key role in ensuring the accuracy, quality, and integrity of health claims decisions by applying clinical knowledge, regulatory awareness, and strong attention to detail. This role demands a balance of technical understanding and operational execution.
Key Responsibilities
Claims Processing: Review, analyze, and process health claims accurately and within turnaround time (TAT) as per internal SOPs and regulatory norms.
Medical Review: Assess the clinical validity of diagnoses, treatments, and procedures in submitted claims, ensuring appropriate application of medical protocols and coding.
Fraud Detection: Identify anomalies, patterns of abuse, or suspicious activities and escalate for investigation or mitigation.
Regulatory Compliance: Ensure all claim decisions adhere to health insurance regulations and company policies.
Policy Interpretation: Interpret product terms and policy coverage to determine admissibility and guide fair settlement decisions.
Requirements
2-5 years of experience in health claims processing with a clinical/medical background
Exposure to health insurance processes is essential
Education: Graduate in any of the following streams: BHMS, BAMS, BDS
Certifications: Not mandatory
Technology Tools: Working knowledge of Microsoft Office Suite (Excel, Word, Outlook)
Behavioral Traits
Communication: Clear and structured communication to convey claim decisions and seek clarifications
Assertiveness: Confidence in decision-making and escalation where needed
Proactiveness: Initiative in identifying trends, inconsistencies, and continuous process improvements
Digit Insurance
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