Sr Associate - Health claims (CL&MR)

ACKO; Bengaluru; On-site; INR 300,000 - 600,000; Full time

Job summary

ACKO is seeking a Health Insurance Claims Analyst in Bengaluru to review OPD and hospital claims, verify documents, ensure compliance with IRDAI regulations, and coordinate with hospitals, TPAs, and internal teams for timely settlements.

Applicants should have MBBS or equivalent and 1-4 years of experience in claims adjudication or hospital billing, with strong analytical skills and MS Office proficiency.

Qualifications

• Graduate MBBS/BAMS/BHMS/BDS
• 1-4 years' experience in health insurance claims adjudication, TPA operations, or hospital billing
• Strong knowledge of health insurance policies, medical terminology, and hospital billing practices
• Ability to interpret policy wordings, exclusions, and benefit clauses
• Analytical thinking with attention to detail
• Good communication and coordination skills
• Proficiency in MS Office and claims management systems

Responsibilities

• Review all open claim files assigned (cashless & reimbursement).
• Verify completeness of documentation (pre-authorization forms, discharge summaries, bills, prescriptions, investigation reports, etc.).
• Check for missing or inconsistent information and initiate follow-ups with hospitals, TPAs, or claimants.
• Evaluate medical necessity of treatments against standard guidelines and policy coverage.
• Identify any non-payable items, exclusions, or excess billing.
• Liaise with medical panel doctors, TPAs, hospital coordinators, and internal claims teams for clarifications.
• Provide accurate updates on claim status and pending requirements.
• Ensure professional and clear communication with all stakeholders.
• Track claim pendency, turnaround time (TAT), and provide periodic reports on open files.
• Contribute to process improvements to minimize open file pendency.
• Assist in root cause analysis for delays and recommend corrective measures.
• Validate medical necessity for consultations, diagnostics, and prescribed medications.
• Cross-check billing and pricing norms against market standards and internal guidelines.
• Flag suspicious or inflated claims for investigation.
• Escalate complex cases to senior medical officers or investigation team where required.
• Provide clear and professional communication to customers regarding claim approvals, deductions, or rejections.
• Adhere to IRDAI regulations and company SOPs in claim adjudication.
• Maintain proper documentation and audit trails for every claim.
• Participate in internal audits and quality checks to ensure process compliance.

Job description

Key Responsibilities

1. File Review & Assessment

• Review all open claim files assigned (cashless & reimbursement).

• Verify completeness of documentation (pre-authorization forms, discharge summaries, bills, prescriptions, investigation reports, etc.).

• Check for missing or inconsistent information and initiate follow-ups with hospitals, TPAs, or claimants.

• Evaluate medical necessity of treatments against standard guidelines and policy coverage.

• Identify any non-payable items, exclusions, or excess billing.

1. Policy & Compliance Verification

• Ensure all claims are adjudicated as per policy wordings, benefit plans, exclusions, and sub-limits (if applicable).

• Maintain compliance with IRDAI regulations and company SOPs.

• Escalate potential cases of fraud, abuse, or misrepresentation to the investigation team.

1. Coordination & Communication

• Liaise with medical panel doctors, TPAs, hospital coordinators, and internal claims teams for clarifications.

• Provide accurate updates on claim status and pending requirements.

• Ensure professional and clear communication with all stakeholders.

1. Quality & Process Improvement

• Track claim pendency, turnaround time (TAT), and provide periodic reports on open files.

• Contribute to process improvements to minimize open file pendency.

• Assist in root cause analysis for delays and recommend corrective measures.

Key Skills & Competencies

• Strong knowledge of health insurance policies, medical terminology, and hospital billing practices.

• Ability to interpret policy wordings, exclusions, and benefit clauses.

• Analytical thinking with attention to detail.

• Good communication and coordination skills.

• Proficiency in MS Office and claims management systems.

Qualifications & Experience

• Graduate MBBS,BAMS,BHMS,BDS.

• 1-4 years' experience in health insurance claims adjudication, TPA operations, or hospital billing.

Performance Indicators (KPIs)

• Timely closure of open claims within defined TAT.

• Accuracy in claim review and adjudication.

• Reduction in repeated queries or rework.

• Compliance adherence (regulatory and internal SOPs).

• Quality of documentation and escalation.

Key Responsibilities

1. Claims Processing & Adjudication

• Receive and validate OPD claims submitted by policyholders (consultation, diagnostics, pharmacy bills, preventive health check-ups, etc.).

• Check claim forms, prescriptions, invoices, and supporting medical documents for accuracy and completeness.

• Verify eligibility, coverage limits, exclusions, and waiting periods under the policy.

• Identify non-payable expenses and process the payable amount as per policy terms.

• Ensure claims are settled within the defined turnaround time (TAT).

1. Medical & Financial Scrutiny

• Validate medical necessity for consultations, diagnostics, and prescribed medications.

• Cross-check billing and pricing norms against market standards and internal guidelines.

• Flag suspicious or inflated claims for investigation.

1. Coordination & Communication

• Liaise with insured members, hospitals, diagnostic centers, and pharmacies for clarifications or missing documents.

• Escalate complex cases to senior medical officers or investigation team where required.

• Provide clear and professional communication to customers regarding claim approvals, deductions, or rejections.

1. Compliance & Quality Assurance

• Adhere to IRDAI regulations and company SOPs in claim adjudication.

• Maintain proper documentation and audit trails for every claim.

Participate in internal audits and quality checks to ensure process compliance.