Claims Specialist

About Job : -

Claims Management Specialist is responsible for processing and managing cashless insurance claims efficiently and accurately, ensuring timely closure to policyholders and seamless coordination with insurance providers.

The job purpose of a Claims Management Specialist is to process and manage cashless claims for employees. This includes verifying policy coverage, reviewing medical records, coordinating with Insurers, and ensuring that claims are processed accurately and efficiently. The processor may also be responsible for communicating with employees or dependants to provide updates on the status of their claims and to address any questions or concerns. Overall, the job purpose is to facilitate the smooth and timely processing of cashless claims to ensure that employees receive the benefits they are entitled to.

PRINCIPAL ACCOUNTABILITIES : -

Act as a Claims buddy - Manage end-to-end cashless claims of employees. This includes verifying policy coverage, reviewing medical records, coordinating with Insurers, and ensuring that claims are processed accurately and efficiently.

Verify Policy Coverage : Review and verify policy details to ensure that the claim is eligible for cashless processing according to the terms and conditions of the insurance policy.

Provide Customer Service : Respond to inquiries from employees, and other stakeholders regarding claim status, and any other related queries.

Coordinate with Healthcare Providers / Hospitals : Communicate with healthcare providers

to obtain additional information, clarify details,( whenever required)

Resolve Issues : Investigate and resolve any discrepancies, errors, or issues that may

arise during the processing of cashless claims to ensure timely and accurate resolution

Maintain Records : Keep detailed and accurate records of all claim-related activities, communications, and transactions for documentation and audit purposes.

Adhere to Service Level Agreements : Meet or exceed established service level

agreements and performance metrics related to claim processing, turnaround time, accuracy, and customer satisfaction.

Achieve NPS of 92+ in the cashless claims handled

INTERACTIONS : -

• Internal Clients :

Endorsement team

Onboarding team

Products & engineering-

Claims teams

Support Inbound

Account Management

Insurers

Client HR’s

Hospitals

Who can apply?

At least 2 years of experience in customer-facing roles

Past Experience in voice profile would be an added advantage

Experience in cashless / TPA