Claims QC Manager For Health Insurance Company

3 days ago

Navi Mumbai, Maharashtra, India Career Shaper Full time ₹ 12,00,000 - ₹ 36,00,000 per year

Role Overview

We are seeking a Claims QC Manager to ensure accuracy, compliance, and fairness in health insurance claim processing. This role involves overseeing both rejection recommendations and approvals (including high-value cases), in alignment with IRDAI regulations, internal policies, and ethical standards. The QC Manager will drive process improvements, mitigate risks, and uphold operational excellence within the Claims QC function.

Key Responsibilities

1. Rejection Review

  • Validate all rejection recommendations for compliance with policy terms, regulatory guidelines, and documentation standards.
  • Collaborate with Claims, Underwriting (UW), and FWA teams on disputed cases.
  • Document and analyze root causes of rejections; report trends and corrective measures to management.

2. QC of Approval Cases

  • Conduct quality checks on approval cases (as per defined thresholds) through detailed review of medical reports and policy terms.
  • Coordinate with Underwriting, Claims, and FWA teams for complex or high-value cases.
  • Escalate ambiguous cases with detailed recommendations to senior leadership.

3. Compliance & Audit

  • Ensure adherence to IRDAI guidelines, internal SOPs, and policy conditions.
  • Conduct periodic audits of approved/rejected claims and suggest improvements via the training team.
  • Implement corrective and preventive measures in coordination with stakeholders.

4. Process Improvement

  • Identify gaps and inefficiencies in claims processing; design and implement process enhancements.
  • Stay updated with industry trends and digital innovations (AI, automation) to strengthen QC frameworks.

5. Reporting & Stakeholder Collaboration

  • Collaborate with Claims, Underwriting, and Customer Service teams to address systemic issues and grievances.

6. Customer Satisfaction

  • Handle escalations related to claim rejections or approvals with transparency and fairness.
  • Ensure timely, compliant, and customer-centric claim decisions to uphold company reputation.

Qualifications

Education:

  • Bachelors degree in Medicine (MBBS/BAMS/BHMS), Healthcare Management, or a related field.

Experience:

  • 3–5 years in Health Insurance or TPA (Claims Processing or QC).
  • Minimum 2 years of core experience in reimbursement health claims.
  • Exposure to fixed benefit cases will be an added advantage.

Skills & Competencies

  • Strong understanding of IRDAI regulations, medical terminology, and claims workflows.
  • Proficiency in claims management systems and tools.
  • Analytical mindset with strong decision-making and conflict-resolution abilities.
  • Ethical judgment, risk management, and result orientation.
  • High attention to detail and ability to learn quickly.
  • Excellent communication and stakeholder management skills.

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