Medical Claims Processor

Overview

Key Accountabilities

• ***1.
• Adjudication and Processing of Claims***
• Review and adjudicate claims accurately and within the required timelines as per TOB and applicable SOPs.
• Ensure full compliance with mandated medical claims adjudication protocols.
• Make claims decisions strictly within policy provisions and authority limits.

Key Performance Indicators

• 98% Accuracy of adjudication
• Compliance with SOP and medical protocols
• Quality scores and error rates post Audit
• ***2.
• Day-to-Day Operations***
• Process all claims assigned by the Line Manager within the defined TAT of 10 Calendar Days
• Achieve daily productivity targets as mandated Management.
• Ensure all claims are processed end‑to‑end within the regulatory requirements.

Key Performance Indicators

• Daily productivity achievement
• TAT compliance with Minimal processing delays
• ***3.
• Additional Responsibilities:***
• Identify and flag audit findings to the Line Manager and audit team for review and any suspected potential fraud with wastage abuse and misuse.
• Provide feedback and recommendations for system enhancements to improve efficiency and reduce provider escalations.

Key Performance Indicators

• Quality and timeliness of feedback
• Reduction in escalations
• Contribution to process improvements

*4. Communication& Working Relationships*

• Collaborate with internal departments (Network, Approvals, IT) to resolve claims‑related issues promptly.
• Support a smooth and cooperative inter‑departmental workflow.

Key Performance Indicators

• Minimal escalations
• Effective cross‑department coordination

Qualifications & Experience

• Bachelor’s degree in Medicine, Healthcare Management, Insurance, Nursing, Pharmacy, or a related field
• Minimum 1–3 years of experience in medical claims processing or healthcare insurance, preferably in payer or TPA environments
• Strong knowledge of medical insurance policies, Table of Benefits (TOB), and claims adjudication processes
• Must have healthcare coding practices (ICD, CPT, or equivalent) certificate

Additional Information

• Contract role for 1 year
• Salary is aligned with entry-level expectations
• Must be able to join immediately