Claim Handler - OPD Claims | Medical Degree Mandatory

Job description

**Role Overview** We are looking for a Claim Handler - OPD Claims, responsible for reviewing, evaluating, and processing insurance claims as per company policies and regulatory guidelines. The role involves medical document review, claim assessment, customer coordination, and claim-related calling while ensuring accuracy, quality, and timely resolution. **Key Responsibilities** - Evaluate, review, and process claims in accordance with company policies, procedures, productivity, and quality standards. - Examine medical documents and assess claim admissibility based on policy terms and conditions. - Review medical claims and verify information for accuracy and completeness. - Coordinate with customers over calls to explain policy terms & conditions, claim details, claim status, and documentation requirements. - Handle customer queries related to claims and provide timely updates/resolutions. - Deliver excellent customer service by addressing policyholder concerns professionally. - Identify discrepancies in claims and coordinate for corrections or additional information. - Examine claims for potential fraud indicators and conduct investigations wherever required. - Gather additional information/documents to determine the validity of claims. - Ensure compliance with company policies, processes, and regulatory requirements. - Maintain productivity and quality standards as per defined expectations. - Process claim payments accurately as per approvals and guidelines. - Adapt to cross-training opportunities and manage multiple claim-related activities. - Perform other claim-related tasks as required. **Required Skills & Competencies** - Good communication skills in **English and Hindi (mandatory)**. - Comfortable with **customer coordination and customer calling**. - Strong customer service skills. - Good medical knowledge and understanding of medical terminology. - Basic understanding of insurance claims process (preferred). - Basic knowledge of IRDAI guidelines will be an added advantage. - Strong analytical and problem-solving skills. - Attention to detail and ability to verify documents accurately. - Ability to multitask and adapt to process requirements. - Basic knowledge of MS Office (Excel, Word, Outlook). **Qualification & Experience** **Qualification (Mandatory):** - Candidate must hold a medical degree/qualification such as: - B.Pharm - Pharm D - B.Sc Nursing - BDS - BHMS - BAMS - Any other relevant medical/healthcare qualification **Experience:** - Freshers can apply. - Candidates with prior experience in health insurance claims, medical claims processing, or healthcare operations will be preferred. **Work Details** - Work Mode: Work from Office (WFO) - Working Days: 6 days working - Weekly Off: 1 rotational week off - Shift Timings: General shift timings - Transport Facility: Not provided - Languages Required: English and Hindi mandatory - Candidate should be open for customer calling and customer coordination as part of the role.