Claims Associate Medical

1 week ago

Bengaluru, Karnataka, India Digit Insurance Full time

Position Overview

Looking to leverage your medical expertise in a dynamic insurance environment As a Claims Associate Medical, you will play a key role in ensuring the accuracy, quality, and integrity of health claims decisions by applying clinical knowledge, regulatory awareness, and strong attention to detail. This role demands a balance of technical understanding and operational execution.

Key Responsibilities

  • Claims Processing: Review, analyze, and process health claims accurately and within turnaround time (TAT) as per internal SOPs and regulatory norms.
  • Medical Review: Assess the clinical validity of diagnoses, treatments, and procedures in submitted claims, ensuring appropriate application of medical protocols and coding.
  • Fraud Detection: Identify anomalies, patterns of abuse, or suspicious activities and escalate for investigation or mitigation.
  • Regulatory Compliance: Ensure all claim decisions adhere to health insurance regulations and company policies.
  • Policy Interpretation: Interpret product terms and policy coverage to determine admissibility and guide fair settlement decisions.

Requirements

Experience:

  • 2-5 years of experience in health claims processing with a clinical/medical background
  • Exposure to health insurance processes is essential
  • Education: Graduate in any of the following streams: BHMS, BAMS, BDS
  • Certifications: Not mandatory
  • Technology Tools: Working knowledge of Microsoft Office Suite (Excel, Word, Outlook)

Behavioral Traits

  • Communication: Clear and structured communication to convey claim decisions and seek clarifications
  • Assertiveness: Confidence in decision-making and escalation where needed
  • Proactiveness: Initiative in identifying trends, inconsistencies, and continuous process improvements

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