Close File Review - Health Claims - Mumbai - Bhandup

Role & responsibilities

1. Claim File Review

• Conduct end-to-end review of closed claim files (cashless & reimbursement).
• Verify correctness of claim adjudication, coding, documentation, and decision rationale.
• Ensure all required documents (policy, KYC, bills, prescriptions, investigations) are present and valid.
• Check medical necessity, line of treatment, and adherence to standard treatment guidelines.

2. Compliance & Quality Checks

• Ensure claim decisions comply with IRDAI regulations and company SOPs.
• Identify any potential non-compliance, financial leakage, or process discrepancy.
• Validate adherence to TAT norms and communication standards.

3. Fraud, Waste & Abuse (FWA) Indicators

• Identify any suspicious patterns, excessive billing, or potential fraud triggers.
• Escalate cases to the FWA/SIU team when required.

4. Documentation & Reporting

• Maintain audit findings, error categories, and scoring sheets.
• Prepare daily/weekly/monthly reports on error trends, root causes, and improvement areas.
• Highlight high-impact errors and suggest process corrections.

5. Coordination & Feedback

• Work closely with claims processing, medical review, provider management, and quality teams.
• Provide feedback to processors/assessors for continuous improvement.
• Participate in calibration sessions to maintain judgment consistency.

6. Process Improvement

• Identify gaps in claim handling and recommend SOP updates.
• Support training initiatives based on audit observations.
• Assist in designing checklists and quality tools for better claim accuracy.

Preferred candidate profile

• Strong knowledge of health insurance products, policy terms, exclusions, and IRDAI guidelines.
• Understanding of medical terminology, hospital billing, ICD/Procedure coding (preferred).
• Analytical mind set with attention to detail.
• Good communication and reporting skills.
• Ability to work under time-bound targets.
• Proficiency in Excel, MIS.