Claims Executive

Role: As a Claims Officer, you will be responsible for the processing and servicing of escalated health insurance claims. Your primary purpose is to coordinate with various stakeholders and meet customers' needs by ensuring timely, appropriate claim settlements. You must be dedicated to improving customer experience through effective problem-solving, acting as a bridge between the customer, PhonePe RMs, and the insurer.
Key Responsibilities:
● Act as a Claims Guide: End-to-end management of cashless/reimbursement escalated claims.
This includes verifying policy coverage, reviewing medical records, coordinating with insurers, suggesting documents for reconsideration and ensuring that claims are processed efficiently.
● Verify Policy Coverage and Eligibility: Review and verify policy details and nuances of customer’s health to ensure that the claim is eligible for processing according to the terms and conditions.
● Coordinate with Stakeholders: Coordinate with insurers and TPAs to obtain additional information, challenge unfair decisions, clarify details, and drive timely claim resolution.
● Provide Exceptional Customer Service: Serve as the point of contact for resolving customer concerns in escalated claim cases. Ensure all customer-facing communication meets standards of empathy and clarity to enhance the client experience.
● Strategic Reporting & Optimization: Track and report on insurer-wise performance and claim cycle times. Utilize these insights to optimize claims processing and overall experience.

● Experience: 2-4 years in health insurance claims processing. Must have prior experience of working in the insurance/TPA industry.
● Education: Bachelor’s degree in life sciences / pharmacy / medical science / nursing is preferred.
● Display a strong understanding of health insurance claims and related regulations/terminologies.
● Core Skills: Negotiation, Problem-Solving, Attention to Detail, Resilience, and Clear
Communication.

Key Performance Indicators (KPIs)
● Resolution TAT for Escalated Claims: Measures the speed and effectiveness in resolving claims concerns. This is the primary KPI.
● Customer Satisfaction (CSAT): Measures customer happiness with the handling and outcome of their claim issues.
● Claims Cycle Time (Insurer-wise Analysis): Measures diligence in tracking and reporting on the end-to-end processing time for each insurance partner to identify systemic delays.