Senior Executive - Claim Processing

1. Claim Processing & Verification

• Receive, review, and process corporate health/general insurance claims submitted by employees or hospitals.
• Validate documents such as invoices, discharge summaries, medical records, and claim forms.
• Verify eligibility, coverage limits, exclusions, and policy terms.
• Check for discrepancies, incomplete documentation, or potential fraud indicators.
• Enter and update claim information into the system accurately.
  

2. Coordination & Communication

• Coordinate with hospitals, corporate HR teams, and insurance companies to obtain documents or clarify queries.
• Communicate clearly with employees/corporate clients regarding claim status, additional requirements, and timelines.
• Liaise with internal teams such as underwriting, accounts, and customer service.
  

3. TPA & Insurance System Management

• Manage claims in TPA/insurance portals as per operational guidelines.
• Ensure adherence to turnaround times (TAT) and service-level agreements (SLA).
• Prepare claim reports and maintain accurate records in claim management systems.
  

4. Compliance & Quality Assurance

• Ensure compliance with IRDAI guidelines, company policies, and TPA agreements.
• Conduct quality checks on processed claims to minimize errors.
• Handle audits and provide necessary documents during inspections.
  

5. Customer Support

• Handle inquiries and resolve claim-related issues for corporate customers.
• Provide guidance on coverage, procedures, documentation, and claim settlement.
• Escalate critical cases to supervisors as needed.
  

Required Skills & Competencies

• Strong understanding of health/general insurance policies, TPA guidelines & claim procedures.
• Good knowledge of medical terminology (for health insurance roles).
• Excellent communication and coordination skills.
• Attention to detail and strong analytical abilities.
• Ability to work with deadlines and handle multiple cases simultaneously.
• Proficiency in MS Office and claim management systems/TPA portals.
  

Qualifications

• Graduate in any discipline (Commerce/Science preferred).
• Certification in insurance (e.g., III, Health Insurance courses) is an advantage.
• 15 years of experience in claim processing, preferably with a TPA or insurance company.
  

Key Performance Indicators (KPIs)

• Claim processing accuracy
• TAT adherence
• Customer satisfaction
• Error/rejection rate
• Compliance & documentation quality