Asst manager / Manager Health Claims

Kshema General Insurance; Hyderabad; On-site; INR 900,000 - 1,300,000; Full time

Job summary

Kshema General Insurance in Hyderabad is seeking an experienced Health Claims Specialist/Team Lead to manage end-to-end health insurance claims, including cashless and reimbursement processes. The role requires ensuring timely settlements, fraud control, and strict compliance with IRDAI guidelines, while delivering a superior customer experience.

You will coordinate with network hospitals and TPAs, review medical documents, and handle escalations.

Qualifications

• Graduate with medical background preferred (MBBS/BAMS/BHMS/BDS/Pharma/Nursing).
• Experience in health claims/TPA advantageous.
• Knowledge of IRDAI guidelines and policy wordings.

Responsibilities

• Claims Processing: verify coverage, eligibility, exclusions and compute payable amount.
• Cashless Claims Management: coordinate with network hospitals/TPAs for pre-authorization.
• Reimbursement Claims Handling: scrutinize bills and timelines.
• Fraud Detection & Risk Control: identify red flags and coordinate with investigators.
• Customer & Stakeholder Management: resolve queries and maintain CSAT.
• Compliance & Documentation: adhere to IRDAI regulations and SOPs; audits.
• MIS & Reporting: track TAT, repudiation, loss ratio; prepare reports.

Skills

Health insurance products

Policy wordings understanding

Medical terminology

Analytical thinking

Attention to detail

Communication skills

Negotiation skills

High volume claims handling

Fraud detection mindset

Education

Graduate (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

1. 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
2. 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
3. Reimbursement Claims Handling
   • Scrutinize bills, discharge summaries, prescriptions, investigation reports
   • Detect discrepancies and request additional documents
   • Process claims accurately within defined timelines
4. 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
5. Customer & Stakeholder Management
   • Interact with customers, hospitals, TPAs, and intermediaries
   • Resolve queries, complaints, and escalations
   • Maintain high customer satisfaction (CSAT)
6. Compliance & Documentation
   • Ensure adherence to IRDAI regulations and company SOPs
   • Maintain proper documentation and audit trails
   • Support internal and external audits
7. 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