Claims Specialist – Medical Insurance

About This Role

Job Title: Claims Specialist – Medical Insurance

(Medical/Health, Group Life & Personal Accident, Workmen compensation)

Job Description/Duties & Responsibilities

• Timely notification of the claims to insurance company. All the claims must be submitted to the insurance company within the same working day.
• Registering the claims in the company internal software as per the requirement
• Maintaining business and claims reports and timely (weekly, fortnightly, monthly) submission to the management for review.
• Educating the client regarding the claims procedure & also identifying the payable & non payable claims as per the policy terms & conditions.
• Analyzing the claim to establish the liability in line with the policy terms and conditions
• Liaising with the client & agents on claims documents
• Checking all the claim documents provided by the client & informing client for any missing information or documents. Consistently updated the claim tracker, ensuring real-time visibility into claim status.
• Reviewing all the claim documents before submitting to the insurance company/ relevant parties to the claim.
• Following up with client on any pending documents/information & maintaining file notes for client & insurance company correspondence/ communication (verbal/written) for future records.
• Liaising with the Insurance company/ Third Party Administrator / Hospitals & arranging claim disbursement within reasonable time frame
• Making sure the claim is settled as per policy terms & conditions. Sound and technical knowledge of the policy terms and conditions is a must.
• Periodic updates to Team Leaders/Management about the claim status and highlighting critical claims on time

· Maintaining good client relationships and taking constant customer feedbacks to improve customer service.

· Enhance product knowledge on constant basis and attend all the training as required by the company

· Pre-authorization-any pending request following up with insurance company/TPA and guiding member accordingly. If it is pending with insurance company, contacting the claim teams and expedite the approval.

· Home country treatment-Prior intimation and also arranging direct billing if the hospital is in network.

· GOP(Guarantee of Payment)-if the member had refferal to any specialist which is not available in their network clinic,will arrange GOP from insurance company.

Requirements

• Bachelor’s degree in medicine.
• Professional certifications in insurance or claims (preferred)
• Minimum 1 years of experience in medical insurance claims handling

Work Location: In person