Sr. Associate - OPD Claims | Claims Processing and Customer Calling

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 (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 • 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.