Claims Executive Health Insurance

As a Claims Processing & Adjudication professional, you will be responsible for evaluating and processing medical/health insurance claims in accordance with policy terms, SOPs, and quality benchmarks. Your role will involve validating coverage, exclusions, sub-limits, and waiting periods against policy documents to ensure accurate claim processing. Ensuring documentation accuracy and compliance is crucial in this role. You will be required to maintain complete and compliant claim files that adhere to IRDAI guidelines and internal policies. Participation in quality control reviews and corrective actions will be necessary to uphold production and quality standards. Additionally, preparing detailed claim notes, summaries, and system entries with zero data discrepancies will be part of your routine tasks. Effective customer communication is key in this position. Handling inbound/outbound calls and emails to explain policy terms and conditions, claim decisions, and necessary documents to customers is essential. Providing timely status updates and resolving customer queries in a professional manner will be a significant aspect of your daily responsibilities. You will also be responsible for fraud detection and investigation. Identifying suspicious patterns, inconsistencies, or potential fraud and escalating for further investigation when necessary will be part of your duties. Conducting basic fact-finding activities such as doctor/hospital verification and requesting additional documents to support validity checks will also be required. In the realm of issue resolution and coordination, you will play a vital role in liaising with hospitals, TPAs, and internal teams to resolve mismatches, billing errors, and document gaps efficiently. Adaptability and continuous improvement are essential in this role. You will need to be able to work across multiple product lines and processes, supporting your peers during peak workloads. Additionally, suggesting process improvements to enhance turnaround time, accuracy, and customer experience will be encouraged. Participation in refresher trainings and staying updated on regulatory changes will also be expected. Keeping track of daily productivity, pending queues, and exceptions, and reporting them to the team lead/manager will be part of your responsibilities. Maintaining secure records and ensuring the confidentiality of customer data at all times is of utmost importance. If you are looking to embark on a full-time career in the field of Claims Processing & Adjudication and are eager to contribute to a dynamic team, we encourage you to apply now at btwgroup.co/careers. Job Types: Full-time, Fresher Work Location: In person For further inquiries, please contact the employer at +91 9503776369.,