Claims Specialist

1 week ago

Thane, India Livlong 365 Full time

Job Title : Senior Executive - Wellness OPD Claims

Experience Required : 1+ years

Location : Thane

Job Overview :

We are looking for a Senior Executive – Claim Processing to join our dynamic OPD (Outpatient Department) Wellness Operations team. The ideal candidate will have strong experience in managing OPD claims in line with company guidelines, insurance regulations, and industry standards. If you are detail-oriented, proactive, and passionate about driving efficiency and quality, we want to hear from you

Key Responsibilities :

  • Manage the OPD claims process, ensuring adherence to company policies, product guidelines, and insurance regulations.
  • Handle all queries, requests, claim rejections, escalations, and grievances with effective resolution.
  • Ensure the timely and accurate closure of all claims within the stipulated TAT (Turnaround Time) and SLAs (Service Level Agreements).
  • Implement quality control measures to scrutinize OPD claims and minimize the company’s risk exposure.
  • Liaise with customers, external vendors, and relevant stakeholders to ensure smooth and accurate processing of claims.
  • Detect and prevent fraud, waste, and abuse, while building triggers to strengthen systems and processes.
  • Ensure strict compliance with process guidelines, legal requirements, and regulatory standards.

Skills and Competencies :

  • Strong analytical thinking and problem-solving abilities.
  • Proactive with a results-oriented mindset.
  • Exceptional interpersonal and communication skills .
  • A customer-centric approach with attention to detail.
  • Ability to handle complex issues and ensure smooth end-to-end claims processing.

Qualifications :

  • BAMS/BHMS with strong knowledge of medical terminology, diseases, treatments, and medical guidelines.
  • Relevant experience in insurance claims processing, including MIS , Excel , and PPT .
  • MBA in Healthcare (preferred, but not mandatory).

Why Join Us?

  • Opportunity to work with a fast-growing and dynamic team.
  • Exposure to industry-leading processes and systems.
  • A supportive and collaborative work environment.

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