Claim Processor

Career Shaper; Mumbai; Hybrid; INR 1,200,000 - 2,400,000; Full time

Job summary

Career Shaper is seeking a Claims Operations professional to lead and optimize indemnity, cashless and reimbursement processes across Health, PA and Travel claims.

The role focuses on driving performance metrics (TAT, accuracy) and maintaining quality standards, while guiding the Claims team and ensuring compliant, consistent decision-making to support client retention and risk management.

Qualifications

• Knowledge of indemnity claims processes and Health, PA, Travel claims.
• Experience in measuring performance metrics like TAT and adjudication accuracy.
• Ability to define standards and audit claims for compliance.
• Experience in portfolio analysis and client service delivery.

Responsibilities

• Maintain uniform quality and TATs for claim decisions.
• Create and maintain standards and protocols for the claims team.
• Audit claims decisions for guideline compliance and authority limits.
• Conduct periodic portfolio analysis on profitability, frequency, and severity.
• Ensure consistent service delivery to retain clients.
• Identify risks to the company and escalate appropriately.
• Execute processes and projects aligned with defined standards.
• Provide inputs for refinement of claims guidelines and procedures.
• Oversee health, PA, and travel claim handling.
• Understand process flows and system fields in claims systems.
• Monitor TAT and accuracy in claims adjudication.

Skills

Claims processes

Claims systems

Performance measurement

Team expectations management

Quality & TAT management

Standards & protocols

Audit of claims decisions

Portfolio analysis

Client retention

Risk identification

Process execution

Job description

Knowledge of Claims processes: Indemnity (Cashless, Reimbursement), Fixed Benefit Products

• Understanding of Claims systems (process flow & System fields) Health, PA & Travel
• Experience in measurement of performance (TAT, accuracy in claims adjudication)
• Expectations management of the Claims team
• TAT & expectations management for specialized business handling.
• Ensure uniformity in quality & maintain TATs of Claims decisions
• Create & maintain standards/protocols for Claims team
• Audit claims decisions in adherence & compliance with the Claims guidelines, uniformity in decisions, and approval authority limits (In house and TPA claims)
• Periodic portfolio analysis: profitability (loss ratio / combined ratio), analyze frequency and severity, medical inflation
• Maintain a consistent service delivery to ensure client retention and satisfaction
• Identify risks to the company and escalation accordingly
• Execution of processes and projects operations, to be in line with defined standards
• Inputs for refinement and development of claims guidelines, policies, and procedures.