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PFB JD for Case Management TM (team member)

Job Position: AM / DM / Manager

Location: Thane Mumbai

Department: Ops Claims

Job Summary

We are seeking detail-oriented individuals to join in our highly dynamic and fast growing case management team in claims operations.

It involves the timely coordination of quality healthcare services to address a client’s specific needs in a cost-effective manner to promote optimal outcomes for customers.

This role focuses on reviewing, analysing the claims, identifying and resolving the abuse, inflation in claims, adherence to policy terms.

The ideal candidate will ensure compliance with policies, prevent financial losses, and uphold the integrity of the claims process while collaborating with internal teams and external healthcare providers with customer centric approach.

Key Responsibilities

• 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
• 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.
• 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.
• Documentation, data analysis & Reporting
• Maintain records of case progress, Identify trends
• Prepare and maintain reports on findings, recommendations for process improvements.
• 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.
  
  

Education

Bachelor’s degree in Medicine (MBBS/BAMS/BHMS), MBA in Healthcare Management, or related field.

Experience

Minimum 2-3 yrs. experience preferably in Hospitals TPA department, Health Insurance, Claim processing, Claim investigation,

Knowledge Requirement

• Familiarity with cashless claim processes, TPAs, and insurer-provider contracts.
• Understanding of health insurance policy terms, Clinical protocols, medical coding (ICD-10, CPT), IRDAI guidelines
  
  

Skills

• Strong clinical knowledge and analytical and problem-solving abilities.
• Excellent communication for negotiations and stakeholder collaboration.
• Proficiency and knowledge of MS Excel, PowerPoint and/or analytics tools
• Knowledge of health insurance terms and IRDA guideline
• Customer first approach and detail oriented
  
  

Key Competencies

• High ethical standards and attention to detail.
• Ability to manage multiple cases in a fast-paced environment.
• Critical thinking to assess complex claims and billing patterns.
• Quick learner and Process oriented.
  
  

Work Environment

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