Health Insurance Claims Quality Auditor

India·MumbaiFull-timemid

Manufacturing & ProductionQuality Manager

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Quick Summary

Overview

This role is for one of Weekday’s clients Min Experience: 1+ yearsLocation: Bengaluru, Pune, Maharashtra, India, Gurgaon, Haryana, India, Delhi, India, Mumbai, Maharashtra,

Technical Tools

Manufacturing & ProductionQuality Manager

Requirements

~1 min read

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.

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.

Responsibilities

~1 min read

→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.

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

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

Nice to Have

~1 min read

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.