
Customer Relationship Manager
2 days ago
Job Summary:
We are seeking a qualified and experienced medical professional with a strong background in health insurance claim settlement and customer service. The ideal candidate will leverage their clinical knowledge to evaluate and process health insurance claims efficiently while ensuring a high level of customer satisfaction. This hybrid role bridges the gap between medical accuracy, regulatory compliance, and empathetic customer support.
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.
Required Qualifications:
Education:
MBBS, BDS, BHMS, BAMS, or equivalent medical degree. Postgraduate qualifications in healthcare or insurance are a plus.
Experience:
Minimum 25 years of experience in health insurance, especially in claims processing, medical underwriting, or TPA operations.
Proven track record of customer service experience in a healthcare or insurance setting.
Skills:
Strong clinical judgment and attention to detail.
- Excellent communication and interpersonal skills.
- Proficient in claims management systems and MS Office.
- Ability to handle sensitive medical information with confidentiality and professionalism.
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