Walk-in | Claim Adjudicator

Karthika Consulting & Solutions; Bengaluru; On-site; INR 350,000 - 550,000; Full time

Job summary

Karthika Consulting & Solutions seeks a Claims Verification specialist to manage end-to-end claim documentation and processing checks. You will verify patient documents, perform multi-level reviews, and coordinate with internal teams to resolve discrepancies.

The role emphasizes meticulous attention to detail and timely case updates. The position involves handling various claim stages, aligning with defined processes, and supporting reopen files as needed.

Responsibilities

• Receive claim-related documents and verify original patient documents for completeness, accuracy and consistency with claim requirements.
• Perform initial, final approval and claim-processing checks as per defined process and checklist.
• Tabulate L0 by matching bill breakup with supporting bill/documentation.
• Conduct L1 checks, reviewing final bill, room rent, BSI, co-payment and length of stay.
• Perform L2 review of ICPs, diagnosis and medical line of treatment.
• Carry out L3 checks relating to room & category, deductions and top-ups.
• Verify physical claim documents from other departments including identity, discharge, receipts and investigations.
• Check condition-specific documents (implants, X-rays, USG or other case documents).
• Identify discrepancies or missing information in payment mode or claim-document requirements.
• Review claim-related queries and coordinate internally to resolve cases; escalate as needed.
• Prepare and support reopen files for issues like TPA short settlement and related processes.
• Maintain claims, documents and case updates in OCTA and other trackers.
• Maintain daily Excel productivity sheet, tabulation/TPA reports and daily outstanding records.
• Track cases and ensure timely completion, follow-up and escalation within process timelines.
• Coordinate with CC and IDE for additional documents or case information as required.
• Provide cross-functional/backup support within the claims function when requested by the manager.

Job description

Key Responsibilities

• Receive claim-related documents and files from the relevant teams and verify the original patient documents for completeness, accuracy and consistency with the applicable claim requirements.


• Perform applicable initial, final approval and claim-processing checks as assigned, in accordance with the defined process and checklist.


• Perform L0 tabulation where applicable by matching the bill breakup with the supporting bill/documentation.


• Perform L1-level checks, including review of the final bill, room rent, BSI, co-payment and length of stay, as applicable.


• Perform L2-level review of ICPs, diagnosis and medical line of treatment, as applicable.


• Perform L3-level checks relating to room & category (R&C), proportionate deductions and top-ups, as applicable.


• Verify physical claim documents received from other departments, including identity documents, discharge documents, receipts and investigation reports.


• Check condition-specific supporting documents, such as implants, X-rays, USG or other documents required based on the case.


• Check applicable payment mode or claim-document requirements and identify discrepancies or missing information for correction/follow-up.


• Review claim-related queries and coordinate internally for the information or documentation required to resolve the case, escalating unresolved matters as required.


• Prepare and support reopen files when required, including cases involving TPA short settlement or other claim-processing issues, and coordinate the required dispatch/process completion.


• Maintain accurate claims, documents and case updates in OCTA and other designated systems or trackers.


• Maintain the required daily Excel productivity sheet, tabulation/TPA reports and daily outstanding records.


• Track assigned cases and pending requirements and ensure timely completion, follow-up and escalation within the applicable process timelines.


• Coordinate with internal departments such as CC and IDE when additional documents, clarification or case information is required.


• Provide reasonable cross-functional / backup support within the claims function when assigned by the reporting manager.