Claim Analyst Cashless (Contract-Based)

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:

• Minimum bachelor's degree in medicine or Nursing or Pharmacy or related health discipline.
• 1-2 years of experience handling cashless health insurance claims
• Understands medical reports, diagnoses, and treatment documentation
• Understands health insurance policy wording and benefit structures
• Understands cashless claim workflows and TPA coordination