Specialist | Health Claims - Retail (Cashless)

Acko; Bengaluru; On-site; INR 600,000 - 900,000; Full time

Job summary

ACKO seeks a Health Claims Adjudicator to ensure accurate, timely processing of retail health insurance claims in line with policy terms and regulatory requirements.

You will review medical records, apply exclusions and waiting periods, and assess hospitalization and Day Care claims while maintaining documentation quality and compliance in a high-volume environment.

Qualifications

• MBBS/BDS/BHMS/BAMS/AYUSH degree required.
• Experience in health insurance claims adjudication (2–5 years).
• Proficiency in MS Excel and claims systems is helpful.

Responsibilities

• Adjudicate cashless health claims within defined TAT.
• Review medical records, bills, treatment details, and policy terms to determine claim admissibility.
• Apply policy exclusions, waiting periods, sub-limits, co-pay, deductibles, and non-payable expenses appropriately.
• Assess hospitalization, Day Care claims.
• Identify cases requiring investigation, medical review, or fraud assessment.
• Raise accurate and relevant queries and ensure timely closure of pending claims.
• Ensure claim decisions, deductions, and repudiations are accurate, justified, and well documented.
• Handle escalations and support grievance resolution with clear claim rationale.
• Maintain required productivity, quality, TAT, and compliance standards.
• Identify process gaps and contribute to improving claim accuracy and customer experience.

Skills

Health claims adjudication

Analytical thinking

Medical terminology

Communication skills

Excel

Documentation

Education

MBBS/BDS/BHMS/BAMS/AYUSH

Tools

MS Excel

Claims systems

Job description

About Us

ACKO is a product-tech company, launched in 2016, solving real-world problems for customers, starting with insurance. And as a customer-first organization serving the digitally-savvy, ACKOʼs value proposition of ʻWelcome Changeʼ focuses on offerings that make insurance simple and hassle-free! With features such as zero commission, zero paperwork, instant renewal, same-day claim settlements, and app-based updates on claims, ACKO is a 'Welcome Change' from traditional insurers.

About Us

ACKO is a product-tech company, launched in 2016, solving real-world problems for customers, starting with insurance. And as a customer-first organization serving the digitally-savvy, ACKOʼs value proposition of ʻWelcome Changeʼ focuses on offerings that make insurance simple and hassle-free! With features such as zero commission, zero paperwork, instant renewal, same-day claim settlements, and app-based updates on claims, ACKO is a 'Welcome Change' from traditional insurers. Having said that, we are not just another conventional insurance firm, or the people consulted solely for "claims"! Anchored in a tech-centric philosophy, ACKOʼs approach fuels innovation, empowering us to develop comprehensive products that cater to every aspect of our customers' insurance requirements. And while we are at it, we put our Ackers at the heart of everything we do. We're not your typical 9-to-5 workplace; we're a vibrant and inclusive bunch of innovators and creators making sure every Ackerʼs idea matters, their voice is heard, and their growth is part of our mission.

Role Purpose

Responsible for accurate and timely adjudication of retail health insurance claims in line with policy terms, medical guidelines, SOPs, and regulatory requirements.

Key Responsibilities

• Adjudicate cashless health claims within defined TAT.
• Review medical records, bills, treatment details, and policy terms to determine claim admissibility.
• Apply policy exclusions, waiting periods, sub-limits, co-pay, deductibles, and non-payable expenses appropriately.
• Assess hospitalization, Day Care claims.
• Identify cases requiring investigation, medical review, or fraud assessment.
• Raise accurate and relevant queries and ensure timely closure of pending claims.
• Ensure claim decisions, deductions, and repudiations are accurate, justified, and well documented.
• Handle escalations and support grievance resolution with clear claim rationale.
• Maintain required productivity, quality, TAT, and compliance standards.
• Identify process gaps and contribute to improving claim accuracy and customer experience.

Key Skills

• Strong knowledge of health insurance claims and policy terms.
• Good understanding of medical terminology and treatment procedures.
• Strong analytical and decision-making skills.
• Attention to detail and ability to handle high-volume claims.
• Good communication and documentation skills.
• Working knowledge of MS Excel and claims systems.

Qualification & Experience

• Medical degree – MBBS/BDS/BHMS/BAMS/AYUSH
• 2–5 years of experience in health insurance claims, TPA, hospital claims, or claims adjudication.