Role & responsibilities To give Claims & Cashless/preauthorization, and scrutiny Medical Reimbursement Claims, and to Process Claims Third Party Administration (Health) services (TPA) Claims and Preauthorization Processing HealthCare Assistance Services High Ratio Claims Management in coordination with Networking and Empanelment Department Monitoring the overall operations of Claims and Preauthorization. Responsible for ensuring efficient response at the level of Preauthorization to maintain TAT. Ensure adherence to processes and controls. Creating the process for claim processing (Cashless and Reimbursement). Co-ordination between Network Hospitals/Preauthorization/Claims. Ensuring a high-quality patient care at customized/optimized cost. Creating the process for claim processing (Cashless and Reimbursement). Preferred candidate profile • Good Excellent oral and written communication, negotiation, and decision-making skills. • Good customer service/relationship skills and ability to work effectively in a fast-paced environment with shifting priorities .Must be willing to work in non - clinic TPA EXPERIENCE mandatory.Clinical Exp.

Roles and Responsibilities Ensuring a positive and professional client service experience.Managing client inquiries via phone, email, online, or in person.Directing client complaints or complex queries to relevant departments in a timely manner.Providing clients with technical assistance on products and services.Expediting serious issues to management toward prompt resolution.Building positive client relations by checking in regularly and following up on active processes.Maintaining client records and documenting processes.Identifying potential client services concerns and facilitating proactive intervention steps.Keeping track of new products on offer, as well as emerging trends in client services.Recommending product improvements based on client services feedback.Desired Candidate Profile 1- 4 years of experience in client services, sales, or a similar role.Exceptional ability in providing professional, efficient, and friendly client services.Ability to coordinate with other departments on client-related matters.Advanced ability to provide technical assistance, resolve issues, and recommend improvements.Willingness and the ability to travel to client locations, when required.Ability to keep updated on new developments in the field of client services.Excellent interpersonal and recordkeeping skills.

As a TPA Department Head focused on investigations, you'll lead a team to conduct thorough inquiries into claims, ensuring accuracy and compliance, while also identifying potential fraud and ensuring smooth claim processing. Conduct objective, fair, thorough, unbiased and timely investigations into allegations of fraud, waste or abuse committed by claimants / providers / any other stakeholders in health insurance claims. Review and research evidence/documents to analyse the overall fact pattern of claim and synthesize data into a professional report with recommendations. Prepare and coordinate field assignments to obtain relevant evidence and information. Coordinate with Corporate office to provide recovery strategies and use legal resources for assistance. Manage and prioritize a large and varied case load effectively and efficiently to achieve positive result. Write Narrative report based on investigation conducted with evidence to support.Key Responsibilities:Lead and Manage Investigation Team:Supervise, train, and mentor investigation staff, ensuring they have the necessary skills and resources to perform their duties effectively. Investigate Claims:Conduct in-depth investigations into health insurance claims, gathering evidence, interviewing witnesses, and analysing data to determine the validity of claims. Fraud Detection and Prevention:Identify potentially fraudulent activities, develop and implement fraud prevention strategies, and report suspicious activity to relevant authorities. Compliance and Regulatory Adherence:Ensure all investigation activities comply with relevant regulations, industry standards, and company policies. Data Analysis and Reporting:Analyse claim data to identify trends, patterns, and areas for improvement, and prepare reports for management and stakeholders. Reporting and Communication:Preparing comprehensive investigation reports, summarizing findings, and making recommendations. Presenting findings and recommendations to management or relevant stakeholders. Collaborating with other teams and external parties as needed. Other Potential Responsibilities:Drafting Suspicious Activity Reports (SARs). Participating in proactive investigative projects. Assisting with drafting and serving subpoenas. Providing information for making arrests. Maintaining expertise in relevant laws, regulations, and industry standards. Staying up-to-date on emerging trends and technologies in the field of investigation. Process Improvement:Continuously evaluate and improve investigation processes to enhance efficiency, accuracy, and effectiveness. Collaboration:Work collaboratively with other departments, such as claims processing and underwriting, to ensure seamless operations and accurate claim adjudication. Decision Making:Make sound decisions regarding claim investigations, considering all relevant factors and evidence. Technical Skills:Proficient in using relevant software and tools for data analysis, investigation, and reporting. Medical Knowledge:Possess a strong understanding of medical terminology, procedures, and healthcare systems. Qualifications:Bachelor's degree in a related field (e.g., Healthcare Administration, Business Administration, or Law). Experience in health insurance claims investigation or a related field. Strong analytical and problem-solving skills. Excellent communication and interpersonal skills. Ability to work independently and as part of a team. Knowledge of relevant regulations and industry standards.

Role & responsibilities Monitoring daily Helpdesk activity. • Monitoring daily outstanding of claims. • Handling team of 3 5 personnel. • Second level escalation point for assigned Clients & Brokers. • Monthly Client visits and attending meetings with HR of Respective corporates. • Monthly meetings with Client / Brokers / Insurers on pending issues. • Co-ordinating with Broker / Insurer for endorsement, policy copy and end to end claim process for all clients assigned. • Schedule roster as per clients requirement. • Maintain excellent relationship with client. • Prepare & Publish MIS reports Daily/Weekly/Monthly to the Manager. • Handle Escalation & High Value claims. • Train the new joiners in the system and on the new developments on clients SLA • Follow-up with the insurance/client/corporate for SLAs renewal. Preferred candidate profile Client Servicing, Business development or Client Relationship Management from TPA / Broking / Health Insurance sector.