Senior Medical Claims Examiner

3 days ago


Mumbai, Maharashtra, India beBeeMedicalClaims Full time ₹ 80,00,000 - ₹ 1,20,00,000
Job Opportunity: Medical Claims Examiner

As a medical claims examiner, you will play a crucial role in ensuring the accuracy of medical claims. Your responsibilities will include reviewing and scrutinizing claims, interpreting ICD coding, evaluating co-pay details, and classifying non-medical expenses.

Key Responsibilities:
  • Verify the medical admissibility of a claim by confirming diagnosis and treatment details
  • Examine claims as per insurance policy terms and conditions
  • Interpret ICD coding, evaluate co-pay details, classify non-medical expenses, room tariff, capping details, differentiation of open billing and package etc.
  • Understand process differences between PA and RI claims and verify necessary details accordingly
  • Verify required documents for processing claims and raise IR in case of insufficiency
  • Coordinate with the LCM team in case of higher billing and with the provider team in case of non-availability of tariff
  • Approve or deny claims as per terms and conditions within TAT
  • Handle escalations and respond to queries accordingly
Required Skills and Qualifications:
  • MBBS, BAMS, BHMS degree from an Indian university
  • Indian registration required
  • 0-5 years of experience as a medical officer/consultant
Benefits:

This role is suitable for junior management level professionals in the hospital/TPA/healthcare/insurance industry. The selected candidate will work in a rotational shift environment, with six weeks off provided per month.



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