Claims Manager

About the role

The Claims Manager will lead health authorization activities, reviewing and adjudicating claim requests from third‑party administrators (TPAs) in line with policy coverage, clinical guidelines and regulatory requirements. The role balances member satisfaction, cost control and compliance while ensuring medically necessary services are authorised promptly.

Key responsibilities

• Receive, verify and evaluate authorization requests against eligibility, benefits, policy coverage and clinical criteria.
• Coordinate clinical reviews with Medical Directors, clinicians and case‑management teams when needed.
• Approve, modify or deny requests within defined turnaround times and communicate decisions to TPAs and stakeholders.
• Request and assess additional medical records, maintain accurate decision logs and support appeals with full documentation.
• Monitor queues to meet service‑level agreements and identify trends for process improvement.
• Collaborate with Claims, Provider Relations, Utilization Management, Case Management and Customer Service teams.

Required profile

• Medical degree (MBBS/MD) recognised by the relevant health authority.
• 3–7 years of clinical practice or health‑insurance claims management experience.
• Experience in pre‑authorization, utilization management or managed care preferred.
• Strong analytical, communication and decision‑making abilities.

Required skills

• HCPCS coding
• ICD‑10 coding
• DRG coding systems
• CPT coding
• Medical terminology
• Treatment protocols
• Health insurance regulations
• Healthcare reimbursement processes