Insurance Claims Specialist

Responsibilities

This job is provided by apna.co Key Responsibilities:

• Medical Review & Claims Adjudication:
  
  

Assess and validate medical claims based on clinical documentation and policy coverage.

Interpret diagnostic reports, treatment plans, and prescriptions to determine claim eligibility.

Coordinate with internal medical teams to ensure accuracy in claims decision-making.

• Customer Interaction & Support:
  
  

Communicate with policyholders, hospitals, and third-party administrators (TPAs) to explain claim decisions in a clear and professional manner.

Handle escalated or complex customer service issues involving medical claims.

Offer support and guidance on claim submission processes and documentation requirements.

• Compliance & Documentation:
  
  

Ensure all claims are processed in compliance with IRDAI regulations and internal guidelines.

Maintain accurate records of claim assessments, approvals, denials, and communications.