Executive - SPOC

HealthIndia Insurance TPA Services; Mumbai Suburban; On-site; INR 400,000 - 700,000; Full time

Job summary

HealthIndia Insurance TPA Services is seeking a dedicated professional to manage approvals and closures of claims, reopen/rectify repudiations, and ensure timely completion of eligible claims through API integrations. The role also covers handling grievances, coordinating with CRM and enrolment teams, and resolving provider-related API errors.

The candidate will coordinate with internal stakeholders to meet defined timelines and support payment status communications across branches.

Responsibilities

• Approvals & Closures: Managing repudiation and buffer approvals.
• Processing reopened or corrected claims per approval hierarchy.
• Ensuring closure of eligible claims via API integration where applicable.
• Process Corrections & Communication: Fixing wrong processing at RFP/medical stage.
• Sending clarification and endorsement-related mails to IC when required.
• Coordinating with CRM teams and branches for payment status updates and claim-related communication.
• Grievance & Escalation Handling: Managing grievances and escalation mails to IC regarding deductions or repudiated claims.
• Coordinating with internal stakeholders for resolution within defined timelines.
• Provider: Managing excluded hospital pop-ups and coordinating with provider team based on processing doctors inputs.
• API error related to provider – coordinate with IC.
• APJ / RSA Integration & Error Resolution: Addressing integration errors including invalid hospital/employee IDs, payee ID updates, ICD coding issues, missing documents, policy service data errors, denial reasons, and approved amount mismatches.

Job description

Job Description:

• Approvals & Closures
  - Managing repudiation and buffer approvals.
  - Reopening and processing closed claims in case of incorrect repudiation, as per approval hierarchy.
  - Ensuring closure of eligible claims through API integration wherever applicable
• Process Corrections & Communication
  - Identifying and correcting wrong processing at RFP or medical stage.
  - Sending clarification and endorsement-related mails to IC when required.
  - Coordinating with CRM teams and branches for payment status updates and claim-related communication.
• Grievance & Escalation Handling
  - Handling grievance claims and escalation mails referred to IC regarding deductions or repudiated claims.
  - Coordinating with internal stakeholders for resolution within defined timelines.
• Provider
  - Managing excluded hospital pop-ups and coordinating with provider team based on processing doctors inputs.
  - API error related to provider – coordinate with IC
• BEM
• Co ordination with Enrolment Team
• APJ / RSA Integration & Error Resolution
  - Addressing APJ integration errors including:
  - Invalid hospital ID / employee ID
  - Payee ID updating
  - Incorrect ICD coding
  - Missing or compressed documents
  - Policy service data errors
  - Denial reason not updated
  - Approved amount mismatch etc.
  - Following up on RSA claim numbers and ensuring system accuracy.