Job Description
Job Description:
- Review and assess cashless and pre‑authorization claims to ensure medical necessity, policy coverage, and document completeness.
- Apply policy benefits, exclusions, limits, and tariffs accurately and consistently.
- Make claim decisions within authority and escalate complex, high‑cost, or medically unclear cases.
- Identify potential over‑treatment, non‑standard procedures, or abnormal cost patterns to support cost containment.
- Ensure claims are processed accurately and within SLA/TAT, maintaining low error rates.
- Coordinate with TPA, hospitals, and internal teams to resolve medical or documentation issues.
- Maintain clear, complete, and audit‑ready claim documentation and decision rationale in the system.
Job Requirements:
- Minimu...