Case Management TM/AM - Mumbai, Thane
Only for registered members Mumbai, Thane, India
1 month ago
Job summary
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.
Responsibilities
- Assess claims for admissibility, medical necessity, and identify irregularities or overbilling.
- Conduct root-cause analysis using claims data, treatment records, and clinical guidelines.
- Ensure cost-effective healthcare service delivery with minimal disputes.
- Audit high-value or high-risk claims and monitor adherence to insurer-provider contracts and IRDAI guidelines.
- 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.
- Maintain case records and prepare analytical reports on claim trends and process gaps.
- Recommend process improvements and best practices to enhance claim quality.
- Educate internal and external stakeholders on ethical billing and compliance.
- Stay updated with ICD/CPT codes, medical protocols, and emerging fraud patterns.
Job description
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