About this role
#### Job Summary:
We are looking for an experienced medical
claims professional from a health insurance company or TPA to assess hospital
treatment cases before financing. The role involves reviewing insurance
coverage, clinical records and estimated hospital expenses to determine claim
admissibility, likely deductions and the expected net insurance reimbursement.
This assessment will support the NBFC’s financing decision.
Key Responsibilities
1. Medical Claims Assessment & Adjudication
- Review health insurance policies, schedules, endorsements, admission notes, clinical records, investigations, treatment plans, hospital estimates, and discharge summaries to assess claim admissibility.
2. Policy Coverage & Eligibility Evaluation
- Evaluate policy terms, waiting periods, pre-existing disease clauses, exclusions, policy continuity, available sum insured, and other coverage conditions to determine reimbursement eligibility.
3. Medical Necessity & Clinical Assessment
- Assess the medical necessity and appropriateness of hospitalisation, proposed treatments, diagnostic procedures, and expected length of stay based on available clinical documentation.
4. Reimbursement Estimation & Deduction Analysis
- Estimate the likely net insurance reimbursement after accounting for co-payments, deductibles, sub-limits, room-rent restrictions, non-payable expenses, and other applicable deductions.
5. Medical Risk Identification & Recommendations
- Identify documentation gaps, clinical inconsistencies, potential misrepresentation, and fraud indicators. Provide clear, documented recommendations to proceed, seek additional information, restrict the assessed amount, or decline financing.
6. Stakeholder Coordination & Case Reassessment
- Coordinate with hospital medical teams, insurance desks, TPAs, and internal credit and operations teams to resolve queries and reassess cases when diagnoses, treatment plans, or hospital estimates change.
7. Claims Validation & Process Improvement
- Compare initial reimbursement estimates with actual insurance settlements to identify variances, improve assessment accuracy, and refine underwriting guidelines and deduction benchmarks.
8. Documentation, Reporting & Turnaround Management
- Maintain comprehensive assessment records, audit trails, turnaround times, and escalation protocols while ensuring consistency, transparency, and timely completion of medical claims assessments .
Requirements
Education: MBBS preferred. BAMS, BHMS, or BDS candidates with strong, directly relevant medical claims adjudication experience will also be considered.
Experience: 4–8 years of relevant experience in Indian health insurance claims, including at least 2 years of hands-on medical assessment or claims adjudication.
Mandatory Experience: Practical experience in reimbursement claims assessment is essential. Cashless pre-authorisation experience is desirable.
Claims Adjudication Expertise: Demonstrated experience in assessing claim admissibility, medical necessity, policy coverage, and payable or reimbursable amounts, rather than solely handling documentation, coordination, or claim tracking.
Insurance Knowledge: Strong understanding of retail and group health insurance policies, policy exclusions, waiting periods, pre-existing diseases, common deductions, and repudiation grounds.
Admission-Stage Assessment: Ability to evaluate incomplete medical records and hospital estimates, identify coverage and clinical risks, and determine the additional information required before financing.
Technical Skills: Working knowledge of Microsoft Excel, claims management systems, and written assessment reporting.
Preferred Background: Experience in insurer-side reimbursement claims, technical health claims, medical adjudication, claims audit, complex or disputed claims, and senior TPA medical assessment.
Additional Advantage: Exposure to insurance reimbursement financing or advance-against-mediclaim products.
Core Competencies: Strong clinical judgement, analytical skills, attention to detail, decision-making ability, and effective stakeholder communication.
Key Performance Indicators (KPIs)
- Accuracy of estimated reimbursement compared with actual insurance settlement.
- Quality and consistency of medical risk assessments and financing recommendations.
- Timely identification of coverage gaps, potential deductions, and documentation deficiencies.
- Assessment turnaround time and completeness of case documentation and audit trails.