Claims Executive

Topgear Consultants; Thane, Mumbai; On-site; INR 350,000 - 600,000; Full time

Job summary

Topgear Consultants in Maharashtra seeks a Claims Review and Cost Management specialist to review medical necessity, assess admissibility of claims, and coordinate with hospitals to resolve disputes.

This role involves data analysis, documentation, regulatory awareness (IRDAI guidelines), and continuous improvement to deliver efficient, compliant claim resolutions for customers.

Responsibilities

• Review claims for admissibility, irregularities, overbilling, or unnecessary procedures.
• Conduct root-cause analyses using claims data, treatment records, and provider contracts.
• Assess medical necessity and cost-effectiveness to minimize disputes.
• Coordinate with network hospitals, doctors and TPAs to resolve disputes in real time.
• Monitor adherence to ICD/CPT coding, regulations, and internal policies; identify non-compliance.

Job description

1. Claim Review:

• Review the claims for admissibility, noted irregularities, overbilling, or unnecessary procedures.
• Conduct root-cause analyses of claims using claims data, treatment records, and provider contracts, standard treatment guidelines and protocols

2. Cost Management, Utilization Review:

• Review plan of care medical necessity and admissibility with cost effectiveness and minimizing claim disputes
• Monitor adherence to insurer-provider contracts, IRDAI guidelines, and internal policies.
• Conduct audits of high-risk claims and hospital billing practices.

3. Communication and Collaboration for Resolution

• Liaise with network hospitals, doctors and internal stake holders (claims, underwriting, FWA) / Third-Party Administrators (TPAs), to resolve disputes in real time for customer.
• Identify non-compliance and get corrective action on identified non-compliant via direct communication for quick resolution.
• Real time coordination with hospitals to clarify discrepancies and ensure adherence to approved treatment protocols for facilitating best customer experience during their claim.

4. Documentation, data analysis & Reporting

• Maintain records of case progress, Identify trends
• Prepare and maintain reports on findings, recommendations for process improvements.

5. Patients advocacy, continuous Learning and quality improvement:

• Educate internal and external stake holders on ethical practices and billing abuse, policy / contract terms
• Stay updated on healthcare regulations, coding standards (ICD, CPT), and emerging fraud tactics.