Assistant Manager - Medical Claims & Service

Job Description:

Primary Role Description: 

• The job holder will be responsible for providing dedicated claims facilitation and resolution support in high-business volume branches.
• The primary focus is to provide end to end assistance for claims service to channel partners, sales team and claimants throughout the claims lifecycle.
• The role encompasses end-to-end claims coordination, including documentation guidance, status tracking and grievance management.
• The incumbent will act as a critical bridge between different stakeholders and the central claims team to proactively resolve processing bottlenecks, expedite settlements, and ensure a seamless, transparent experience from submission to resolution.

Key Roles & Responsibilities:

1. Claims Facilitation & Escalation: Act as a bridge between the sales team, partners, and the central claims team to expedite the processing of pending claims and resolve bottlenecks.
2. Elite Partner & Customer Support: Provide dedicated support to CEO/CDO/National Head Club agents and customers regarding claim status updates, documentation requirements, and grievance handling.
3. Claims Documentation & Verification: Ensure all claim documents, medical records, and KYC/AML checks are uploaded, indexed, and verified with 100% accuracy before submission to the central team.
4. Regulatory & Audit Compliance: Maintain strict adherence to internal and regulatory guidelines for claim reporting and data privacy.

Key Performance Indicator (KPI)

• Query Resolution: Significant reduction in pending claim queries and TAT for claim settlement.
• Service Excellence: Achievement of target CSAT/NPS scores specific to the claims experience.
• FTR (First Time Right): >98% accuracy in claim document collection to prevent rejections or delays.
• Audit Compliance: Zero critical errors in claim document indexing and regulatory reporting.

Key Requirements – Education & Certificates:

• Must be a medical graduate i.e BDS, BPT, BHMS, BAMS, BUMS, etc

Key Requirements - Experience & Skills:

• A minimum of 1+ years of experience in a health or medical insurance claims  servicing.
• Strong knowledge of medical terminology, insurance claim procedures, and billing codes.
• Excellent verbal and written communication skills.
• Strong problem-solving and decision-making abilities.
• Attention to detail and accuracy in data entry and documentation.
• Exceptional customer service skills with a friendly and professional demeanor.
• Proficiency in using computer systems, including customer relationship management (CRM) software and Microsoft Office Suite.
• Ability to work effectively in a team-oriented environment.