Medical Assessor - BHMS/BDS/BAMS (1.5-2yrs exp in insurance)

Claims Associate Medical

Company

Department

Position Overview

Looking to leverage your medical expertise in a dynamic insurance environment? As a Claims Associate – Medical, you will play a key role in ensuring the accuracy, quality, and integrity of health claims decisions by applying clinical knowledge, regulatory awareness, and strong attention to detail. This role demands a balance of technical understanding and operational execution.

Key Responsibilities

• Claims Processing: Review, analyze, and process health claims accurately and within turnaround time (TAT) as per internal SOPs and regulatory norms.
• Medical Review: Assess the clinical validity of diagnoses, treatments, and procedures in submitted claims, ensuring appropriate application of medical protocols and coding.
• Fraud Detection: Identify anomalies, patterns of abuse, or suspicious activities and escalate for investigation or mitigation.
• Regulatory Compliance: Ensure all claim decisions adhere to health insurance regulations and company policies.
• Policy Interpretation: Interpret product terms and policy coverage to determine admissibility and guide fair settlement decisions.

Requirements

Experience:

• 2–5 years of experience in health claims processing with a clinical/medical background
• Exposure to health insurance processes is essential

Education: Graduate in any of the following streams: BHMS, BAMS, BDS

Certifications: Not mandatory

Technology Tools: Working knowledge of Microsoft Office Suite (Excel, Word, Outlook)

Behavioral Traits

• Communication: Clear and structured communication to convey claim decisions and seek clarifications
• Assertiveness: Confidence in decision-making and escalation where needed
• Proactiveness: Initiative in identifying trends, inconsistencies, and continuous process improvements

Why This Role Matters

As a medical professional in the health claims domain, your assessments are critical to ensuring fair claim outcomes, detecting inefficiencies, and protecting customer trust. You’ll be the clinical backbone in a process that balances customer care and operational excellence.

Be a part of a team where medical judgment meets insurance precision.