Health Claims Executive

Job Description

Job Title: Claims Executive – Cashless & Reimbursement Location: Mumbai Department: Policybazaar for Business (PBFB) Job Summary: As a Claims Executive at Policybazaar for Business, you will be responsible for managing and processing both cashless and reimbursement insurance claims efficiently. Your role will involve liaising between customers, insurance companies, and healthcare providers to ensure timely and accurate claim settlements while maintaining compliance with company policies and regulatory guidelines. Key Responsibilities: 1. Cashless Claims Processing Coordinate with hospitals and insurance providers to facilitate seamless cashless claim approvals. Verify documentation and eligibility criteria for cashless treatments under health insurance policies. Liaise with hospitals for pre-authorization of treatments, investigations, and procedures. Track claim status and follow up proactively to expedite approvals. Resolve any discrepancies or issues in claim requests with relevant stakeholders. 2. Reimbursement Claims Processing Review and validate reimbursement claims submitted by policyholders. Check claim documents for completeness, accuracy, and compliance with policy terms. Coordinate with customers for any additional information or clarifications required. Process claims within defined timelines and escalate delayed claims as needed. Assist in claims settlement and communicate decisions to customers. 3. Customer Service & Communication Serve as a point of contact for customers regarding claim queries and updates. Maintain professional and clear communication with clients, hospitals, and insurers. Provide guidance on claim procedures and policy coverage. 4. Compliance & Documentation Ensure all claims are processed according to internal SOPs and regulatory requirements. Maintain accurate records and documentation for audit and reporting purposes. Identify potential fraudulent claims and escalate for further investigation. 5. Reporting & Coordination Generate daily/weekly reports on claim status, pendency, and resolution metrics. Collaborate with cross-functional teams such as underwriting, sales, and legal as needed. Participate in continuous process improvement initiatives to enhance claims handling efficiency. Skills & Qualifications: Bachelor’s degree in any discipline (preferably Commerce, Business, or Insurance). 1-3 years of experience in insurance claims processing, preferably health insurance. Understanding of health insurance products, cashless and reimbursement claim workflows. Strong analytical and problem-solving skills. Excellent communication and interpersonal abilities. Proficient in MS Office (Excel, Word) and claims management software or ATS. Detail-oriented with the ability to handle multiple claims simultaneously. Ability to work under pressure and meet deadlines. Preferred: Experience with insurance companies, TPA (Third Party Administrators), or healthcare providers. Knowledge of regulatory compliance and insurance laws. Familiarity with fraud detection practices in insurance claims. Show more Show less