Claims - Case Management

Topgear Consultants; Navi Mumbai; On-site; INR 600,000 - 1,000,000; Full time

Job summary

Topgear Consultants in Thane invites applications for Medico Claims Case Management. You will review and manage health insurance claims, coordinate with hospitals and TPAs, assess medical documentation, and ensure timely resolution of cases.

The role requires MBBS/BAMS/BHMS and 4+ years in Insurance/TPA, with strong communication and stakeholder management.

Qualifications

• MBBS/BAMS/BHMS are mandatory.
• Minimum 4 years of experience in Insurance / TPA, preferably in claims or case management.
• Strong understanding of health insurance claims processing.

Responsibilities

• Review and assess health insurance claims for medical admissibility and accuracy.
• Evaluate medical records, treatment details and claim documentation.
• Coordinate with hospitals, doctors, TPAs and internal stakeholders for claim resolution.
• Handle claim-related queries, discrepancies and escalations.
• Support medical necessity assessment, claim investigation and case management.
• Negotiate and communicate effectively with healthcare providers and stakeholders.
• Ensure adherence to insurance policies, medical protocols and regulatory guidelines.
• Maintain accurate case documentation and reports.

Skills

Communication skills

Negotiation skills

Stakeholder management

Education

MBBS / BAMS / BHMS

Job description

Job Title: Medico Claims Case Management

Industry: Health Insurance / Insurance / TPA

Location: Thane, Maharashtra

Experience: 4+ Years

Education: MBBS / BAMS / BHMS

We are hiring experienced Medico Professionals for our Claims Case Management team based in Thane.

The role involves reviewing and managing health insurance claims, coordinating with hospitals and TPAs, assessing medical documentation and treatment requirements, and ensuring timely resolution of claims.

Key Responsibilities

• Review and assess health insurance claims for medical admissibility and accuracy.
• Evaluate medical records, treatment details and claim documentation.
• Coordinate with hospitals, doctors, TPAs and internal stakeholders for claim resolution.
• Handle claim-related queries, discrepancies and escalations.
• Support medical necessity assessment, claim investigation and case management.
• Negotiate and communicate effectively with healthcare providers and stakeholders.
• Ensure adherence to insurance policies, medical protocols and regulatory guidelines.
• Maintain accurate case documentation and reports.

Candidate Requirements

• MBBS / BAMS / BHMS mandatory.
• Minimum 4 years of experience in Insurance / TPA, preferably in claims or case management.
• Strong understanding of health insurance claims processing.
• Excellent communication, negotiation and stakeholder management skills.
• Candidates from Provider Network, Claim Investigation or similar medico roles will be preferred.
• Candidates should have strong analytical and problem‑solving abilities.

Note: Candidates with experience limited to hospitals, clinical practice or self-practice without Insurance/TPA experience will not be considered.