Insurance Claims Specialist

Key Responsibilities:

·        Medical Review & Claims Adjudication:

• Assess and validate medical claims based on clinical documentation and policy coverage.
• Interpret diagnostic reports, treatment plans, and prescriptions to determine claim eligibility.
• Coordinate with internal medical teams to ensure accuracy in claims decision-making.

·        Customer Interaction & Support:

• Communicate with policyholders, hospitals, and third-party administrators (TPAs) to explain claim decisions in a clear and professional manner.
• Handle escalated or complex customer service issues involving medical claims.
• Offer support and guidance on claim submission processes and documentation requirements.

·        Compliance & Documentation:

• Ensure all claims are processed in compliance with IRDAI regulations and internal guidelines.

Maintain accurate records of claim assessments, approvals, denials, and communications.