Asst manager / Manager Health Claims

Kshema General Insurance Limited; Balanagar; On-site; INR 600,000 - 900,000; Full time

Job summary

Kshema General Insurance Limited in Telangana, India is seeking a Senior Health Claims Specialist to manage end-to-end health insurance claims (cashless and reimbursement), ensure timely settlements, and uphold fraud controls.

You will verify coverage, adjudicate claims, coordinate with hospitals and TPAs, and maintain compliance with IRDAI guidelines while delivering excellent customer experience.

Qualifications

• Graduate with medical background preferred.
• Insurance certifications such as III or LOMA preferred.
• 5–10 years of experience in health claims processing.

Responsibilities

• Manage end-to-end health insurance claims (cashless & reimbursement).
• Verify coverage, eligibility, exclusions, and sub limits.
• Assess admissibility and compute payable amount.
• Ensure timely TAT for claim processing.
• Coordinate with network hospitals and TPAs for pre-authorization.
• Review medical documents and supporting reports.
• Detect fraud indicators and support risk control.
• Maintain documentation and audit trails for compliance.
• Prepare MIS reports on claims metrics.

Skills

Health insurance knowledge

Policy wording understanding

Medical terminology

Analytical thinking

Communication skills

Fraud detection mindset

Detail orientation

Working under pressure

Negotiation skills

Education

Graduate with medical background

Insurance certifications (III/LOMA)

Job description

Role Purpose

To manage end to end health insurance claims (cashless & reimbursement), ensuring timely settlement, fraud control, compliance, and superior customer experience.

Key Responsibilities

• Claims Processing

Handle cashless and reimbursement claims as per policy terms and IRDAI guidelines

• Verify coverage, eligibility, exclusions, and sub limits
• Assess claim admissibility and compute payable amount
• Ensure TAT adherence for claim processing
• Cashless Claims Management
• Coordinate with network hospitals and TPAs for pre authorization
• Review medical documents, treatment plans, and estimates
• Approve/deny requests with proper justification
• Handle escalations from hospitals and customers
• Reimbursement Claims Handling
• Scrutinize bills, discharge summaries, prescriptions, investigation reports
• Detect discrepancies and request additional documents
• Process claims accurately within defined timelines
• Fraud Detection & Risk Control
• Identify red flags, inflated billing, and fraudulent claims
• Coordinate with investigation teams and field surveyors
• Ensure compliance with internal fraud control mechanisms
• Customer & Stakeholder Management
• Interact with customers, hospitals, TPAs, and intermediaries
• Resolve queries, complaints, and escalations
• Maintain high customer satisfaction (CSAT)
• Compliance & Documentation
• Ensure adherence to IRDAI regulations and company SOPs
• Maintain proper documentation and audit trails
• Support internal and external audits
• MIS & Reporting
• Track claim metrics: TAT, repudiation ratio, loss ratio, leakage
• Prepare periodic reports for management review

Key Skills & Competencies

• Strong understanding of health insurance products & policy wordings
• Knowledge of medical terminology and treatment protocols
• Analytical thinking and attention to detail
• Good communication and negotiation skills
• Ability to handle high volume claims under pressure
• Fraud detection mindset

Requirements

Educational Qualification

Graduate (Medical background preferred: MBBS/BAMS/BHMS/BDS/MBBS/Pharma/Nursing)

Insurance certifications (e.g., III/LOMA) preferred

Experience

5–10 years (Senior Claims Specialist / Team Lead)

Experience in health claims / TPA