Insurance Claims Manager|Health Claims

4 days ago

Bhopal, Madhya Pradesh, India Optimus Medical Services Full time

Job Description

Insurance Claims Manager – Health Claims (MP State Operations)

Location: Madhya Pradesh

Department: Health Insurance Claims

Reporting To: State Head / Operations Head

Role Summary

The Insurance Claims Manager – Health Claims will be responsible for managing and overseeing end-to-end health insurance claims operations across Madhya Pradesh. The role involves ensuring timely claim processing, compliance with policy guidelines, coordination with hospitals and field teams, and maintaining high service quality and TAT adherence.

Key Responsibilities

  • Manage end-to-end health insurance claims operations for Madhya Pradesh state.
  • Ensure timely processing, adjudication, and settlement of cashless and reimbursement claims.
  • Monitor and improve Turnaround Time (TAT) and operational efficiency.
  • Coordinate with hospitals, TPAs, insurers, and network partners.
  • Handle complex, high-value, and escalated claims.
  • Ensure adherence to IRDAI regulations, policy terms, and internal SOPs.
  • Supervise and guide state-level claims teams and field officers.
  • Conduct quality audits and implement corrective actions.
  • Analyze claims data to identify fraud, leakage, and trends.
  • Prepare and present MIS reports to management.
  • Support empanelment, renewal, and performance review of network hospitals.
  • Drive process improvements and cost containment initiatives.

Eligibility & Qualifications

  • Bachelor's degree in any discipline (MBA/PG preferred).
  • 6–10 years of experience in health insurance claims management.
  • Prior experience handling state-level operations is mandatory.
  • Strong knowledge of cashless & reimbursement claims, policy interpretation, and medical terminology.
  • Working knowledge of IRDAI guidelines.
  • Experience in managing field officers / off-roll teams will be an added advantage.

Skills & Competencies

  • Strong leadership and people management skills.
  • Excellent communication and negotiation abilities.
  • Analytical mindset with attention to detail.
  • Ability to manage escalations and meet strict deadlines.
  • Proficiency in MS Excel, MIS reporting, and claims systems.
  • Willingness to travel within Madhya Pradesh.

Job Types: Full-time, Permanent

Pay: ₹35, ₹50,000.00 per month

Work Location: In person

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