Executive - Cashless Claim Processing

• Receive and process

  cashless hospitalization requests (pre-authorization forms)

  from network hospitals.

• Verify policy details

  , coverage, and eligibility of insured members in the system.

• Assess and evaluate

  medical details provided by hospitals as per insurance policy terms, internal SOPs, and IRDA guidelines.

• Coordinate with hospital authorities

  to obtain required documents or clarifications.
• Liaise with

  insurance companies or medical officers

  for case approvals or escalations.
• Prepare and send

  authorization letters

  or denial letters within defined timelines.

• Monitor and track ongoing hospitalization cases

  , ensuring timely updates and approvals for enhancement requests.
• Maintain accurate documentation and update case status in the TPA system.
• Support the

  claims team

  in the final settlement process after patient discharge.
• Ensure compliance with

  IRDA regulations

  , TAT (Turnaround Time) standards, and organizational policies.
• Handle

  customer queries

  (patients, hospitals, or insurers) with professionalism and empathy.

Qualifications and Skills:

• Education:

  Graduate in any discipline

• Experience:

  13 years of experience in cashless operations, claims processing, or hospital billing (TPA/Health Insurance industry preferred).

• Technical Skills:

• Knowledge of health insurance processes and terminology.
• Familiarity with TPA software / hospital management systems.
• Proficiency in MS Office (Word, Excel, Email).

• Soft Skills:

• Strong communication and coordination skills.
• Good analytical and decision-making ability.
• Attention to detail and accuracy.
• Ability to work under pressure and meet tight deadlines.
• Customer service orientation.

Key Performance Indicators (KPIs):

• Turnaround time (TAT) for pre-authorization and enhancement requests.
• Accuracy in processing cashless approvals/denials.
• Compliance with policy and IRDA guidelines.
• Customer (hospital/patient) satisfaction level.
• Reduction in case escalations or rework.