Claims Analyst

Company Description Connect and Heal (CNH Care) is an employer-led healthcare platform that helps organizations deliver preventive care, OPD access, and 24×7 health support to employees and their families. Over the past six years, CNH has built one of India’s largest enterprise healthcare networks, serving 400+ organizations and impacting more than 6 million lives. The platform integrates clinical expertise, nationwide coverage, and technology to make employee healthcare seamless, compliant, and outcome-focused. CNH offers services such as preventive health checks, diagnostics, pharmacy access, teleconsultations, emergency support, chronic care management, and hospital assistance. With a vast network of doctors, hospitals, clinics, diagnostics centers, pharmacies, and ambulances across thousands of pin codes and hundreds of cities, CNH enables employers to enhance employee wellbeing and streamline healthcare operations.
Role Description This is a full-time, on-site Claims Analyst role based in Bengaluru. The Claims Analyst will review, verify, and process healthcare and insurance claims in accordance with company policies and payer requirements. Responsibilities include validating claim documentation, checking eligibility and coverage, identifying discrepancies or inconsistencies, and coordinating with internal teams and external stakeholders to resolve issues. The role involves analyzing claim trends, ensuring accurate and timely claim settlements, maintaining detailed records, and supporting process improvements to enhance claim handling efficiency. The Claims Analyst will also respond to queries, provide clear explanations on claim decisions, and help maintain high standards of compliance and customer service.
Key Responsibilities
1. Claim Processing
Review, assess, and process various types of health insurance claims including reimbursement claims, OPD claims, and pre-authorization requests. Ensure all submitted documents are complete, valid, and meet the insurer’s requirements before proceeding with claim evaluation.
2. Medical Adjudication
Analyze medical documents such as prescriptions, invoices, diagnostic reports, and discharge summaries to evaluate medical necessity. Ensure that treatments and procedures are clinically justified and fall within the coverage guidelines defined by the insurance
policy.
3. Financial Accuracy
Accurately calculate the admissible claim amount by applying policy-specific conditions such as room rent capping, sub-limits, co-payments, and proportionate deductions. Ensure all financial calculations are precise and well-documented to avoid discrepancies.
4. Compliance and Policy Adherence
Ensure that all claim decisions strictly adhere to the policy terms and conditions, insurer guidelines, and applicable regulatory requirements. Maintain consistency and fairness in claim adjudication to minimize errors and escalations.
5. Data Management and Documentation
Perform accurate data entry in claim processing systems and maintain detailed records of all claim decisions including approvals, partial approvals, and denials. Ensure proper documentation for audit and future reference.
6. Workflow and TAT Management
Efficiently manage high claim volumes by prioritizing high-value and time-sensitive cases.Ensure all claims are processed within the defined Turnaround Time (TAT) while maintaining quality and accuracy.
Required Qualifications and Skills
- Doctor of Pharmacy (PharmD) is mandatory.
- Minimum 1 year of experience in healthcare claims processing or medical adjudication.
- Strong understanding of medical terminology, treatments, and clinical documentation.
- Knowledge of health insurance policies, claim processes, and adjudication guidelines.
- Proficiency in MS Office, especially Excel, for data analysis and reporting.
- Strong analytical skills with attention to detail.
- Ability to manage workload efficiently and meet deadlines.

Work arrangement
No