The Health Insurance Claim Auditor is responsible for reviewing and evaluating health insurance claims to ensure accuracy, compliance with policies and regulations, and proper payment. They play a crucial role in safeguarding the financial integrity of Acko while ensuring fair and prompt claim processing for policyholders.

Review and Analyze Claims: Thoroughly examine health insurance claims submitted by hospitals, physicians, and other healthcare providers.
Verify Information: Ensure the accuracy of diagnosis codes, treatment procedures, service dates, and other claim details.
Adhere to Policies and Regulations: Apply relevant insurance policies, government regulations, and coding guidelines to assess claim eligibility and payment amounts.
Identify Potential Fraud and Abuse: Analyze claims for potential discrepancies, inaccuracies, or suspicious patterns that suggest fraud or abuse.
Investigate Claims: Conduct investigations into questionable claims by gathering additional information and documentation from providers and policyholders.
Communicate Effectively: Interact with healthcare providers, policyholders, and internal departments to clarify information, obtain documentation, and resolve discrepancies.
Maintain Documentation: Document all findings, decisions, and communication related to each claim reviewed.
Stay Current: Regularly update their knowledge of insurance policies, coding systems, and industry regulations.
Contribute to Continuous Improvement: May analyze claim data and trends to identify areas for improvement in claims processing procedures.
Role: Claims Executive
Industry Type: IT Services & Consulting
Department: BFSI, Investments & Trading
Employment Type: Full Time, Permanent
Role Category: General Insurance
Education
UG: Any Graduate
PG: Any Postgraduate
Key Skills
AuditorHealth insuranceInsurance claimsComplianceCodingFinanceHealthcareContinuous improvementClaims processingAuditing