Job Description

This role is for one of Weekday's clients
Salary range: Rs 400000 - Rs 600000 (ie INR 4-6 LPA)
Min Experience: 4 years
Location: Mumbai
JobType: full-time
Requirements
We are seeking a meticulous and experienced Health & Legal Claims Specialist with a strong background in life insurance claims management. The ideal candidate will be responsible for managing and processing health-related claims, evaluating legal aspects of claims, ensuring compliance with insurance regulations, and maintaining high standards of customer service. This role requires a combination of analytical, legal, and risk management skills, with the ability to handle complex claims efficiently.
The specialist will work closely with underwriters, legal teams, healthcare providers, and clients to review, assess, and process claims while mitigating risks and ensuring timely settlements. The position demands strong attention to detail, knowledge of life insurance policies, and a proactive approach to resolving claims-related issues.
Key Responsibilities

• Claims Assessment: Review and assess health-related and legal claims under life insurance policies to determine validity and adherence to policy terms.
• Legal & Regulatory Compliance: Ensure that all claims processing aligns with applicable regulations, insurance guidelines, and company policies.
• Documentation & Investigation: Collect, verify, and analyze medical records, policy documents, legal notices, and other supporting materials to facilitate claims evaluation.
• Risk Mitigation: Identify potential fraudulent claims, discrepancies, or legal complications, and escalate cases to senior management or legal advisors as required.
• Coordination & Liaison: Work closely with medical professionals, legal teams, insurers, and claimants to gather necessary information and facilitate smooth claim settlements.
• Claims Processing & Settlement: Prepare detailed claim reports, recommendations, and approvals; ensure timely disbursement of valid claims.
• Policy Interpretation: Interpret insurance policies and clauses to provide guidance on coverage, exclusions, and claims procedures.
• Training & Advisory: Assist in educating internal teams and stakeholders about health claims processes, regulatory changes, and legal implications.
• Customer Service: Provide clear communication to claimants, addressing queries, and maintaining high levels of customer satisfaction.
• Reporting & Analytics: Maintain accurate records of claims, analyze trends, and generate periodic reports for management review and strategic decision-making.

Requirements & Qualifications

• Bachelor's degree in Law, Life Sciences, Insurance, or related field; a Master's degree is a plus.
• 4+ years of experience in life insurance claims handling, health claims, or legal claims management.
• Strong understanding of life insurance policies, medical terminologies, and claims procedures.
• Familiarity with regulatory frameworks governing health and life insurance claims.
• Excellent analytical, investigative, and problem-solving skills.
• Strong communication and negotiation skills to interact effectively with clients, legal authorities, and internal teams.
• Proficiency in claims management software and MS Office tools.
• Ability to work independently, manage multiple claims simultaneously, and meet strict deadlines.

Skills Required