Assistant Manager Claims

Key Roles and Responsibilities

1. Claim Intimation and Registration

• Receive claim intimations from clients and assist them throughout the claim process.
• Register claims with the respective insurance companies and TPAs within the prescribed timelines.
• Ensure accurate submission of claim details and obtain claim reference numbers.

2. Claim Documentation and Processing

• Coordinate with clients, hospitals, insurance companies, and TPAs for the collection and submission of required claim documents.
• Verify claim forms, bills, discharge summaries, investigation reports, prescriptions, and other supporting documents.
• Ensure timely submission of documents and compliance with insurer requirements.

3. Claim Follow-up and Settlement

• Regularly follow up with insurance companies and TPAs for claim status, queries, approvals, and settlements.
• Monitor pending claims and ensure timely resolution of outstanding requirements.
• Communicate claim updates and settlement decisions to clients.
• Coordinate for cashless pre-authorisation, enhancement requests, discharge approvals, and reimbursement claims, wherever applicable.

4. Query Management and Claim Resolution

• Respond to insurer queries in coordination with clients and healthcare providers.
• Identify discrepancies in claim assessments, deductions, repudiations, and short settlements.
• Raise reconsideration requests, grievances, and escalations wherever justified.
• Coordinate with insurers for claim review and resolution of disputed deductions.

5. Client Servicing and Support

• Provide end-to-end assistance to clients during the claim process.
• Explain claim procedures, documentation requirements, policy terms, exclusions, and settlement decisions in understandable language.
• Maintain professional communication and ensure a satisfactory client experience.

6. MIS and Reporting

• Maintain accurate records of claim intimations, pending claims, settlements, repudiations, and outstanding queries.
• Prepare regular claim status reports and MIS for clients and management.
• Track turnaround times, pending documentation, and claim settlement performance.
• Maintain proper records of email communications and claim-related documents.

7. Coordination and Compliance

• Coordinate with relationship managers, insurance companies, TPAs, hospitals, and internal departments.
• Ensure adherence to internal processes, insurer guidelines, applicable regulatory requirements, and data confidentiality standards.
• Maintain an organised claim database and ensure timely closure of claim files.
• Required Skills and Competencies Good written and verbal communication skills.
• Strong follow-up, coordination, and negotiation skills.
• Knowledge of health insurance policies, claim procedures, and documentation.
• Ability to analyse claim deductions, queries, and repudiation reasons.
• Proficiency in MS Excel, email communication, and claim management portals.
• Good organisational skills, attention to detail, and problem-solving ability.
• Ability to manage multiple claims and work within defined timelines.