Sr. Associate - OPD Claims | Claims Processing and Customer Calling

Acko; Bengaluru; On-site; INR 300,000 - 520,000; Full time

Job summary

Acko in Bengaluru is seeking a Claim Handler - OPD Claims to review, evaluate, and process insurance claims in line with policies and regulatory guidelines. The role involves medical document review, claim assessment, customer coordination, and claim-related calling while ensuring accuracy, quality, and timely resolution.

You will analyze medical documents, assess admissibility, coordinate with customers via calls, explain policy terms, and ensure accurate, timely resolutions while maintaining

Qualifications

• Medical degree or healthcare qualification as listed.
• Freshers can apply.
• Experience in health insurance claims preferred.
• Good medical knowledge and terminology.

Responsibilities

• Review, evaluate, and process OPD insurance claims per policies and regulatory guidelines.
• Examine medical documents and assess claim admissibility based on policy terms.
• Coordinate with customers via calls to explain policy terms, claim details, and required documentation.
• Identify discrepancies in claims and coordinate corrections or additional information.
• Process claim payments accurately as per approvals and guidelines.
• Ensure compliance with company policies and regulatory requirements.

Skills

English

Hindi

Customer coordination

Customer service

Medical terminology

MS Office

Education

B.Pharm

Pharm D

B.Sc Nursing

BDS

BHMS

BAMS

Other healthcare qualification

Job description

Role Overview

We are looking for a Claim Handler - OPD Claims, responsible for reviewing, evaluating, and processing insurance claims as per company policies and regulatory guidelines. The role involves medical document review, claim assessment, customer coordination, and claim-related calling while ensuring accuracy, quality, and timely resolution.

Key Responsibilities

• Evaluate, review, and process claims in accordance with company policies, procedures, productivity, and quality standards.
• Examine medical documents and assess claim admissibility based on policy terms and conditions.
• Review medical claims and verify information for accuracy and completeness.
• Coordinate with customers over calls to explain policy terms & conditions, claim details, claim status, and documentation requirements.
• Handle customer queries related to claims and provide timely updates/resolutions.
• Deliver excellent customer service by addressing policyholder concerns professionally.
• Identify discrepancies in claims and coordinate for corrections or additional information.
• Examine claims for potential fraud indicators and conduct investigations wherever required.
• Gather additional information/documents to determine the validity of claims.
• Ensure compliance with company policies, processes, and regulatory requirements.
• Maintain productivity and quality standards as per defined expectations.
• Process claim payments accurately as per approvals and guidelines.
• Adapt to cross-training opportunities and manage multiple claim-related activities.
• Perform other claim-related tasks as required.

Required Skills & Competencies

• Good communication skills in English and Hindi (mandatory).
• Comfortable with customer coordination and customer calling.
• Strong customer service skills.
• Good medical knowledge and understanding of medical terminology.
• Basic understanding of insurance claims process (preferred).
• Basic knowledge of IRDAI guidelines will be an added advantage.
• Strong analytical and problem-solving skills.
• Attention to detail and ability to verify documents accurately.
• Ability to multitask and adapt to process requirements.
• Basic knowledge of MS Office (Excel, Word, Outlook).

Qualification (Mandatory)

• Candidate must hold a medical degree/qualification such as:
• B.Pharm
• Pharm D
• B.Sc Nursing
• BDS
• BHMS
• BAMS
• Any other relevant medical/healthcare qualification
• Freshers can apply.
• Candidates with prior experience in health insurance claims, medical claims processing, or healthcare operations will be preferred.

Work Details

• Work Mode: Work from Office (WFO)
• Working Days: 6 days working
• Weekly Off: 1 rotational week off
• Shift Timings: General shift timings
• Transport Facility: Not provided
• Languages Required: English and Hindi mandatory
• Candidate should be open for customer calling and customer coordination as part of the role.