Claims Retrospective Associate – Medical Claims

About the role

This position ensures that complex, high‑cost medical claims are assessed accurately, fairly and within agreed service levels. You will work closely with claims processors, providing expert guidance on coverage and medical aspects while supporting the team’s productivity targets.

Key responsibilities

• Review high‑cost reimbursement and direct medical claims against policy terms and medical guidelines.
• Answer queries from claims processors and help resolve issues affecting turnaround time and quality.
• Maintain accurate records of claim decisions to support audit and compliance requirements.
• Identify potential fraud or inconsistencies and escalate according to risk procedures.
• Collaborate with risk management, quality teams and other departments to improve claims processes.

Required profile

• Bachelor’s degree in a medical, paramedical or related field.
• 1–2 years experience in clinical, paramedical, TPA, insurance or customer‑facing roles.
• Familiarity with insurance policies, claims procedures and regulatory requirements.
• Strong analytical attention to detail and effective communication skills.

Required skills

• Proficiency in MS Office.
• Experience with claims management or data analysis tools.