Claim Processor

Career Shaper; Thane; On-site; INR 600,000 - 900,000; Full time

Job summary

Career Shaper in Thane is seeking a Claims Operations Specialist/Manager to lead end-to-end adjudication across Health and Personal Accident claims, ensuring accuracy, timely processing, and regulatory compliance. You will oversee indemnity, cashless and reimbursement processes, and drive process improvements.

You will mentor claims adjudication teams, conduct audits with in-house and TPA partners, and analyze portfolio metrics to optimize loss ratios and overall efficiency.

Qualifications

• 0–10 years of experience in claims operations.
• Experience with Health and Personal Accident claims.
• Strong understanding of end-to-end adjudication processes.

Responsibilities

• Manage end-to-end indemnity and fixed benefit claims processes.
• Ensure adherence to TAT benchmarks, adjudication accuracy, and approval limits.
• Conduct regular audits for In-House and TPA claims decisions.
• Lead adjudication teams and drive uniform quality standards.
• Analyze portfolio metrics: loss ratios, combined ratios, frequency/severity.
• Refine SOPs and drive continuous process improvements.

Skills

Claims adjudication

Audit governance

Team mentoring

Portfolio analysis

Job description

Role: Claims Operations

Industry: Insurance (General / Health / TPA)

Location: Thane

Experience: 0 to 10 Years

Role Overview

We are hiring a Claims Operations Specialist/Manager to lead end-to-end adjudication, quality governance, and audit workflows across Health, Personal Accident (PA)

Key Responsibilities

• Manage end-to-end Indemnity (Cashless & Reimbursement) and Fixed Benefit claims processes.
• Ensure strict adherence to TAT benchmarks, adjudication accuracy, and approval authority limits.
• Conduct regular audits for both In-House and TPA claims decisions to ensure regulatory compliance.
• Lead and mentor claims adjudication teams; drive uniform quality standards.
• Analyze portfolio metrics: loss ratios, combined ratios, frequency/severity, and medical inflation.
• Refine claims SOPs, mitigate exposure risks, and drive continuous process improvements.