Claims QC Manager For Health Insurance Company -INDIA

Role Overview

Claims QC Manager

Key Responsibilities

1. Rejection Review

• Validate all rejection recommendations for compliance with policy terms, regulatory guidelines, and documentation standards.
  
• Collaborate with Claims, Underwriting (UW), and FWA teams on disputed cases.
  
• Document and analyze root causes of rejections; report trends and corrective measures to management.
  

2. QC of Approval Cases

• Conduct quality checks on approval cases (as per defined thresholds) through detailed review of medical reports and policy terms.
  
• Coordinate with Underwriting, Claims, and FWA teams for complex or high-value cases.
  
• Escalate ambiguous cases with detailed recommendations to senior leadership.
  

3. Compliance & Audit

• Ensure adherence to

  IRDAI guidelines

  , internal SOPs, and policy conditions.
• Conduct periodic audits of approved/rejected claims and suggest improvements via the training team.
  
• Implement corrective and preventive measures in coordination with stakeholders.
  

4. Process Improvement

• Identify gaps and inefficiencies in claims processing; design and implement process enhancements.
  
• Stay updated with industry trends and digital innovations (AI, automation) to strengthen QC frameworks.
  

5. Reporting & Stakeholder Collaboration

• Collaborate with Claims, Underwriting, and Customer Service teams to address systemic issues and grievances.
  

6. Customer Satisfaction

• Handle escalations related to claim rejections or approvals with transparency and fairness.
  
• Ensure timely, compliant, and customer-centric claim decisions to uphold company reputation.
  

Qualifications

Education:

• Bachelors degree in

  Medicine (MBBS/BAMS/BHMS)

  , Healthcare Management, or a related field.

Experience:

• 3–5 years

  in Health Insurance or TPA (Claims Processing or QC).

• Minimum 2 years

  of core experience in reimbursement health claims.
• Exposure to

  fixed benefit cases

  will be an added advantage.

Skills & Competencies

• Strong understanding of

  IRDAI regulations

  , medical terminology, and claims workflows.
• Proficiency in

  claims management systems and tools

  .
• Analytical mindset with strong decision-making and conflict-resolution abilities.
  
• Ethical judgment, risk management, and result orientation.
  
• High attention to detail and ability to learn quickly.
  
• Excellent communication and stakeholder management skills.