Claims Executive

1. Claim Review:

• Review the claims for admissibility, noted irregularities, overbilling, or unnecessary procedures.

• Conduct root-cause analyses of claims using claims data, treatment records, and provider contracts, standard treatment guidelines and protocols

2. Cost Management, Utilization Review:

• Review plan of care medical necessity and admissibility with cost effectiveness and minimizing claim disputes

Monitor adherence to insurer-provider contracts, IRDAI guidelines, and internal policies.

• Conduct audits of high-risk claims and hospital billing practices.

3. Communication and Collaboration for Resolution

• Liaise with network hospitals, doctors and internal stake holders (claims, underwriting, FWA) / Third-Party Administrators (TPAs), to resolve disputes in real time for customer.

• Identify non-compliance and get corrective action on identified non-compliant via direct communication for quick resolution.

• Real time coordination with hospitals to clarify discrepancies and ensure adherence to approved treatment protocols for facilitating best customer experience during their claim.

4. Documentation, data analysis & Reporting

• Maintain records of case progress, Identify trends

• Prepare and maintain reports on findings, recommendations for process improvements.

5. Patients advocacy, continuous Learning and quality improvement:

• Educate internal and external stake holders on ethical practices and billing abuse, policy / contract terms

• Stay updated on healthcare regulations, coding standards (ICD, CPT), and emerging fraud tactics.