Health Insurance Claims Quality Auditor

This role is for one of Weekday’s clients

Min Experience: 1+ years
Location: Bengaluru, Pune, Maharashtra, India, Gurgaon, Haryana, India, Delhi, India, Mumbai, Maharashtra, India
JobType: full-time

We are looking for a detail-oriented Health Insurance Claims Quality Auditor to ensure the accuracy, quality, and compliance of health insurance claims processed by the TPA team. The role involves reviewing claim assessments, validating medical documentation, identifying discrepancies, and ensuring adherence to policy terms, medical guidelines, internal quality standards, and established claims processing protocols.

The ideal candidate must have a medical qualification such as BAMS, BHMS, or MBBS, along with relevant experience in the health insurance or Third-Party Administrator (TPA) industry.

Key Responsibilities

• Conduct quality checks and audits of processed health insurance claims.
• Review claim documents, medical reports, hospital bills, and supporting records to ensure accuracy and completeness.
• Verify that claims are processed in accordance with policy terms, medical guidelines, and TPA protocols.
• Identify errors, discrepancies, and deviations in claim processing and recommend appropriate corrective actions.
• Validate the medical justification for treatments, procedures, and hospitalization expenses.
• Ensure compliance with internal quality standards and applicable regulatory guidelines.
• Coordinate with claims processing and medical teams to investigate and resolve discrepancies.
• Prepare quality audit reports and maintain records of audit observations and corrective actions.
• Identify recurring errors and recommend process improvements to enhance claim quality, accuracy, and operational efficiency.

Required Qualifications

• BAMS, BHMS, or MBBS is mandatory.
• Candidates without the specified medical qualifications will not be considered.
• Relevant experience in the Health Insurance or TPA industry is mandatory.

Required Skills and Experience

• Understanding of health insurance claims assessment and processing.
• Experience in claims auditing and quality control.
• Ability to review medical documentation, hospital bills, and treatment records.
• Knowledge of policy terms, medical guidelines, and TPA claims protocols.
• Strong analytical skills and attention to detail.
• Ability to identify discrepancies and recommend corrective measures.
• Good communication and coordination skills.

Must-Have Skills

• Health Insurance Claims Assessment
• Claims Auditing
• Quality Control
• Health Insurance / TPA Industry Experience

Good-to-Have Skills

• Medical Claim Scrutiny
• Medical Claim Validation
• Claims Assessment Auditing
• Quality Assurance in Health Insurance

Preferred Candidate Profile

• Candidates with hands-on experience in medical claim scrutiny and validation will have an added advantage.
• Prior exposure to health insurance claims assessment, auditing, or quality control is preferred.
• Strong understanding of medical documentation and hospitalization-related expenses.