Team Member - Case Management

Role Overview

This position sits within the claims operations function and is based in Thane, Mumbai, Maharashtra, India. The team is looking for detail-focused professionals who can support case management work in a fast-paced, expanding environment. The role is centered on coordinating healthcare services in a timely and cost-conscious way so that customer outcomes are improved.

The job involves evaluating claims, spotting possible abuse or inflated billing, checking compliance with policy terms, and helping protect the company from financial leakage. A strong customer-centric mindset is important, along with the ability to work closely with internal teams and healthcare providers.

Core Work Areas

• Examine claims for eligibility, irregularities, excess billing, and avoidable procedures.
• Use claims data, treatment records, provider agreements, treatment standards, and protocols to identify root causes.
• Assess medical necessity and admissibility while keeping costs under control and reducing claim disputes.
• Track compliance with insurer-provider contracts, IRDAI requirements, and internal rules.
• Audit high-risk claims and hospital billing practices.
• Coordinate with network hospitals, doctors, internal teams such as claims, underwriting, and FWA, as well as TPAs, to resolve issues quickly.
• Address non-compliance through direct communication and drive corrective action for faster closure.
• Work in real time with hospitals to resolve discrepancies and support approved treatment pathways for a better customer experience.
• Maintain case records, track progress, identify patterns, and prepare reports with recommendations for process improvement.
• Educate internal and external stakeholders on ethical conduct, billing misuse, and policy or contract terms.
• Keep learning about healthcare regulations, coding standards such as ICD and CPT, and new fraud trends.

Education and Experience

Applicants should hold a bachelor’s degree in Medicine (MBBS, BAMS, or BHMS), an MBA in Healthcare Management, or a related discipline.

The preferred experience is 2 to 3 years in hospitals, TPA departments, health insurance, claim processing, or claim investigation.

Knowledge and Skills Needed

• Working knowledge of cashless claim processes, TPAs, and insurer-provider arrangements.
• Understanding of health insurance terms, clinical protocols, medical coding (ICD-10 and CPT), and IRDAI guidelines.
• Strong clinical understanding paired with analytical and problem-solving ability.
• Good communication skills for negotiation and coordination with multiple stakeholders.
• Comfort using MS Excel, PowerPoint, and analytics tools.
• Detail-oriented approach with a customer-first mindset.
• High ethical standards and the ability to evaluate complex claim and billing patterns.
• Capability to handle multiple cases in a busy environment.
• Quick learning ability and process discipline.

Additional Information

Job position levels mentioned for this opening are AM, DM, and Manager. The department is Ops Claims. The work environment section was present in the source, but no further details were provided.