Case Management TM/AM

1 week ago

Navi Mumbai, Maharashtra, India Career Shaper Full time

About the Role

We are looking for experienced and detail-oriented professionals to join our Claims Case Management Team. The role involves reviewing and analyzing health insurance claims, ensuring accuracy, compliance, and cost-effectiveness while maintaining a strong customer-centric approach.

You will collaborate closely with hospitals, TPAs, and internal teams to identify irregularities, prevent financial losses, and uphold the integrity of the claims process.

Key Responsibilities

1. Claim Review & Analysis

  • Assess claims for admissibility, medical necessity, and identify irregularities or overbilling.
  • Conduct root-cause analysis using claims data, treatment records, and clinical guidelines.

2. Cost Management & Utilization Review

  • Ensure cost-effective healthcare service delivery with minimal disputes.
  • Audit high-value or high-risk claims and monitor adherence to insurerprovider contracts and IRDAI guidelines.

3. Communication & Stakeholder Coordination

  • Liaise with hospitals, TPAs, doctors, and internal departments (Claims, Underwriting, FWA) for dispute resolution.
  • Address non-compliance through proactive communication and ensure smooth claim resolution.

4. Documentation, Reporting & Analytics

  • Maintain case records and prepare analytical reports on claim trends and process gaps.
  • Recommend process improvements and best practices to enhance claim quality.

5. Continuous Learning & Advocacy

  • Educate internal and external stakeholders on ethical billing and compliance.
  • Stay updated with ICD/CPT codes, medical protocols, and emerging fraud patterns.

Educational Qualification

  • MBBS / BAMS / BHMS / MBA (Healthcare Management) or equivalent medical or healthcare qualification.

Experience

  • 2–3 years in Health Insurance, Claims Processing, TPA Operations, or Hospital Billing/Investigation.

Skills & Competencies

  • Strong clinical and analytical skills.
  • Excellent communication and negotiation abilities.
  • Proficiency in MS Excel, PowerPoint, and data analysis tools.
  • In-depth knowledge of health insurance, medical protocols, and IRDAI compliance.
  • Ethical mindset, attention to detail, and process orientation.
  • Ability to manage multiple cases in a fast-paced, high-volume environment.

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