Claims Manager - Medical Claim Audit (S5)

<div>About the Team<br>The &nbsp;Process &nbsp;Excellence &nbsp;team &nbsp;at &nbsp;Navi &nbsp;is &nbsp;focused &nbsp;on &nbsp;maintaining &nbsp;and &nbsp;elevating &nbsp;the<br>quality &nbsp;of &nbsp;customer &nbsp;interactions. &nbsp;As &nbsp;the &nbsp;quality &nbsp;audit &nbsp;function, &nbsp;the &nbsp;team &nbsp;conducts<br>regular audits of agent communications—across calls, chats, and other channels—to<br>ensure &nbsp;accuracy, &nbsp;consistency, &nbsp;and &nbsp;compliance. &nbsp;The &nbsp;team &nbsp;also &nbsp;ensures &nbsp;compliance<br>across &nbsp;different &nbsp;verticals &nbsp;and &nbsp;runs &nbsp;multiple initiatives in coordination with business<br>team stakeholders to drive key business metrics. Insights from these audits are used<br>to &nbsp;drive &nbsp;continuous &nbsp;improvement &nbsp;through &nbsp;targeted &nbsp;training, &nbsp;helping &nbsp;agents &nbsp;close<br>knowledge or process gaps and deliver a consistently excellent customer experience.<br><br>About the Role<br>We are seeking an experienced doctor with medical knowledge for the process excellence vertical to<br>join our dynamic team. &nbsp;As a vital member of our Process Excellence team, a quality auditor dedicated<br>exclusively &nbsp;to &nbsp;auditing &nbsp;claims &nbsp;processed &nbsp;by &nbsp;medical &nbsp;officers &nbsp;to &nbsp;ensure &nbsp;accuracy, &nbsp;compliance, &nbsp;and<br>continual improvement. A quality auditor conducts detailed reviews of claims, identifying areas for<br>improvement..<br>What We Expect From You<br>● &nbsp;The role involves identifying discrepancies, fraud, or errors in claims to ensure<br>compliance with health insurance policies and regulatory requirements &nbsp;<br>● &nbsp;Review &nbsp;health &nbsp;claims &nbsp;for &nbsp;accuracy, &nbsp; completeness, &nbsp;and &nbsp;compliance &nbsp;with<br>insurance policies and applicable regulations. &nbsp;<br>● &nbsp;Identify any inconsistencies, overbilling, or discrepancies between the services<br>provided and the claims submitted &nbsp;<br><br>● &nbsp; Detect &nbsp; potential &nbsp; fraudulent &nbsp; claims &nbsp;by &nbsp;analyzing &nbsp;patterns &nbsp;and &nbsp;identifying &nbsp;<br>suspicious &nbsp;activities &nbsp;or behaviors &nbsp;<br>● &nbsp;Suggest process improvements to enhance the efficiency and accuracy of the<br>claims audit process. &nbsp;<br>● &nbsp;Stay &nbsp;updated &nbsp;with &nbsp;industry &nbsp;trends, &nbsp;regulations, &nbsp;and &nbsp;changes &nbsp;in &nbsp;healthcare<br>policies that may impact claims auditing.<br><br>Must Haves<br><br>● &nbsp;Medical Graduate in any stream (MBBS/BHMS/BAMS/BUMS/BDS) &nbsp;<br>● &nbsp;Experience in handling an audit &nbsp;<br>● &nbsp;Background in claims processing with clinical experience in a hospital setting &nbsp;<br>● &nbsp;Data analytics experience would be an added advantage &nbsp;<br>● &nbsp;Knowledge of different languages would be an added advantage. Proficiency in<br>Hindi and English is mandatory. &nbsp;<br>● &nbsp;Knowledge of health insurance policies and regulations, IRDAI circulars is a must &nbsp;<br>● &nbsp;Strong analytical and problem-solving skills. &nbsp;<br>● &nbsp;Excellent attention to detail and ability to spot discrepancies &nbsp;<br>● &nbsp;Ability to anticipate potential problems and take appropriate corrective action &nbsp;<br>● &nbsp;Effective communication skills for working with different stakeholders &nbsp;<br>● &nbsp;Time management skills to meet deadlines. &nbsp;<br>● &nbsp;Should have a broad understanding of Claims Practice &nbsp;<br>● &nbsp;Sharp business acumen to understand health insurance claim servicing needs &nbsp;<br>● &nbsp;Excellent communication skills, including writing reports and presentations<br><br>Inside Navi<br>We &nbsp;are &nbsp;shaping the future of financial services for a billion Indians through products<br>that &nbsp;are &nbsp;simple, &nbsp;accessible, &nbsp;and &nbsp;affordable. &nbsp;From &nbsp;Personal &nbsp;&amp; &nbsp;Home &nbsp;Loans &nbsp;to &nbsp;UPI,<br>Insurance, Mutual Funds, and Gold — we’re building tech-first solutions that work at<br>scale, with a strong customer-first approach. &nbsp;<br><br><br>Founded &nbsp;by &nbsp;Sachin &nbsp;Bansal &nbsp;&amp; &nbsp;Ankit &nbsp;Agarwal &nbsp;in &nbsp;2018, &nbsp;we &nbsp;are &nbsp;one &nbsp;of &nbsp;India’s<br>fastest-growing financial services organisations. But we’re just getting started!<br>Our Culture<br>The Navi DNA &nbsp;<br>Ambition. Perseverance. Self-awareness. Ownership. Integrity.<br>We’re looking for people who dream big when it comes to innovation. At Navi, you’ll be<br>empowered &nbsp;with &nbsp;the &nbsp;right &nbsp;mechanisms &nbsp;to &nbsp;work &nbsp;in &nbsp;a &nbsp;dynamic &nbsp;team &nbsp;that &nbsp;builds and<br>improves &nbsp;innovative &nbsp;solutions. &nbsp;If &nbsp;you’re &nbsp;driven to deliver real value to customers, no<br>matter the challenge, this is the place for you.<br>We chase excellence by uplifting each other—and that starts with every one of us.<br><br>Why You'll Thrive at Navi<br>At Navi, it’s about how you think, build, and grow. You’ll thrive here if:<br>● &nbsp;You’re impact-driven : You take ownership, build boldly, and care about making<br>a real difference.<br>● &nbsp;You strive for excellence : Good isn’t good enough. You bring focus, precision,<br>and a passion for quality.<br>● &nbsp;You &nbsp;embrace &nbsp;change &nbsp;: &nbsp;You &nbsp;adapt &nbsp;quickly, &nbsp;move &nbsp;fast, &nbsp;and &nbsp;always &nbsp;put &nbsp;the<br>customer first. </div>