Job Description

Medical Claims Executive - Role & Responsibilities

A Medical Claims Executive acts as a critical link between patients, healthcare providers, and payers (insurance companies or government schemes). The primary role is to ensure accurate and timely processing of medical bills and claims, in compliance with scheme-specific guidelines such as CGHS, ECHS, TPA, and CSMA.

Preference:

Retired Army Personnel will be given preference, particularly those with prior experience in ECHS / CGHS medical claims handling.

Core Roles and Responsibilities

Claim Submission: Preparation and submission of medical claims to insurance companies and government authorities.

Documentation Verification: Reviewing patient records, treatment details, and supporting documents for accuracy and completeness.

Medical Coding: Ensuring correct ICD and CPT coding to avoid claim discrepancies and rejections.

Follow-up & Resolution: Tracking claim status, following up on pending or rejected claims, and resolving issues with payers and patients.

Compliance: Ensuring adherence to healthcare regulations and scheme-specific billing guidelines.

Reporting: Preparing reports on claim status, revenue trends, and billing performance for management review.

Scheme-Specific Responsibilities

CGHS & ECHS (Government Schemes):

Strict adherence to government-approved package rates and empanelment rules.

Coordination for pre-authorization approvals (especially for ECHS cases).

Maintaining precise documentation for audit by government bill-clearing agencies.

Guiding beneficiaries regarding cashless and reimbursement procedures.

TPA (Third Party Administrator):

Managing cashless hospitalization and reimbursement claims.

Acting as a liaison between hospital, TPA, and insurance companies.

Verifying patient eligibility and policy coverage prior to admission.

resolving discrepancies and responding to TPA queries promptly.

CSMA (Central Services Medical Attendance Rules):

Handling reimbursement claims for Central Government employees.

Ensuring compliance with CSMA rules, approved rates, and submission timelines.

Coordinating submission of original bills, reports, and discharge summaries.

Staying updated with MoHFW circulars and special sanctions.

Preference:

Retired Army Personnel will be given preference, particularly those with prior experience in ECHS / CGHS medical claims handling.

Job Types: Full-time, Permanent

Work Location: In person