About Plum Plum is an employee insurance and health benefits platform focused on making health insurance simple, accessible and inclusive for modern organizations. Healthcare in India is seeing a phenomenal shift with inflation in healthcare costs 3x that of general inflation. A majority of Indians are unable to afford health insurance on their own; and so as many as 600mn Indians will likely have to depend on employer-sponsored insurance. Plum is on a mission to provide the highest quality insurance and healthcare to 10 million lives by FY2030, through companies that care. Plum is backed by Tiger Global and Peak XV Partners. JOB PURPOSE:- The job purpose of a claim adjudication specialist who is a doctor is to use their Medical expertise and knowledge to build a smooth claims experience for the end customer. Toi review and evaluate medical decisions made by insurance companies based on the medical documents submitted by the end customer. PRINCIPAL ACCOUNTABILITIES
- Review and assess complex health insurance claims to determine coverage and eligibility for payment
- Investigate and verify claim information, including policy details, medical records, and other relevant documentation
- Working with Insurance companies to ensure all relevant claims are paid to the customer as per the terms agreed
- Helping customers understand the complex medical requirements (wherever required) in ensuring a smooth claim processing
- Ensure compliance with regulatory requirements and company policies and procedures in the claims adjudication process
- Provide guidance and support to junior claims adjudication specialists and other team members as needed
- Collaborate with internal departments, in helping them resolve complex medical queries coming out of the Insurance claims.
- Act as a COE for medical queries within the organization
- Stay up to date on industry trends, best practices, and regulatory changes related to claims adjudication
Who can apply
- MBBS/BHMS/BDS and a good understanding of medical terminologies
- 2+ years experience in health claims processing/approval in domestic Insurance companies or TPAs
- Excellent communication skills
- Good negotiation skills
- Responsive, accountable and detailed oriented creative thinker with a strong bias for action
