Process Associate - Claims
5d ago
source : Shine

PA- Claims Assessor

To assess claims products to ensure that benefit spend is in accordance with the policies and rules relevant to our members policies and contracted agreements with providers of Healthcare.


Data Entry of Information related to personal details, provider details, invoice information, procedure & impairment codes

Validation of information entered by indexer

Check & Select correct Preauthorization

Identify duplicate Claims and take appropriate action

Reading & taking appropriate action on Alerts related to Members & providers.

Referring case to calling team for further information

Validating information entered by data Entry Operator

Dealing with Policy & Non Policy messages

Interpreting, analyzing & further investigating the Policy messages on various tools like support point, info site etc.

Interpretation of hospital contracts & taking appropriate action basis that

Referring cases to various department like HCS,TMT, Triage after adjudication as and when required

Identify any over charge, ineligible chargers, contract compliance, Provider or Member Fraud


Minimum qualifications


Preferred qualifications

B.Sc. Life Science

Good knowledge of healthcare & medical terminologies

Eye for detail & investigative skills

Good interpretation & comprehension skills

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