Claims Processor

Key Responsibilities 

• Receive claim-related documents and files from the relevant teams and verify the original patient documents for completeness, accuracy and consistency with the applicable claim requirements. 

• Perform applicable initial, final approval and claim-processing checks as assigned, in accordance with the defined process and checklist. 

• Perform L0 tabulation where applicable by matching the bill breakup with the supporting bill/documentation. 

• Perform L1-level checks, including review of the final bill, room rent, BSI, co-payment and length of stay, as applicable. 

• Perform L2-level review of ICPs, diagnosis and medical line of treatment, as applicable. 

• Perform L3-level checks relating to room & category (R&C), proportionate deductions and top-ups, as applicable. 

• Verify physical claim documents received from other departments, including identity documents, discharge documents, receipts and investigation reports. 

• Check condition-specific supporting documents, such as implants, X-rays, USG or other documents required based on the case. 

• Check applicable payment mode or claim-document requirements and identify discrepancies or missing information for correction/follow-up. 

• Review claim-related queries and coordinate internally for the information or documentation required to resolve the case, escalating unresolved matters as required. 

• Prepare and support reopen files when required, including cases involving TPA short settlement or other claim-processing issues, and coordinate the required dispatch/process completion. 

• Maintain accurate claims, documents and case updates in OCTA and other designated systems or trackers. 

• Maintain the required daily Excel productivity sheet, tabulation/TPA reports and daily outstanding records. 

• Track assigned cases and pending requirements and ensure timely completion, follow-up and escalation within the applicable process timelines. 

• Coordinate with internal departments such as CC and IDE when additional documents, clarification or case information is required. 

• Provide reasonable cross-functional / backup support within the claims function when assigned by the reporting manager.