| Detail | For this role |
|---|---|
| Department | Insurance |
| Level | Mid level |
| Reports to | Claims Manager |
| Direct reports | None |
| Experience | 1 to 4 years in health claims or a hospital billing desk |
Health Claims Analyst job description template
Copy this job description, replace the text in square brackets and post it on your careers page or a job portal.
Job title: Health Claims Analyst
Department: Insurance
Reports to: Claims Manager
Location: [City], [office, branch or site]
About the role
A Health Claims Analyst adjudicates health insurance claims, deciding what is payable against the policy terms for cashless and reimbursement cases. They check medical bills, treatment details and policy conditions, coordinate with hospitals and third party administrators, and settle or query claims. The role reports to the Claims Manager. A good health claims analyst settles genuine claims quickly and correctly, applies policy terms and exclusions fairly, catches over billing and non payable items, keeps queries clear so members are not troubled needlessly, and controls leakage on the health book.
Key responsibilities
- Adjudicate cashless and reimbursement health claims against the policy terms.
- Check medical bills, treatment details and discharge summaries for what is payable.
- Apply policy conditions, sub limits, waiting periods and exclusions fairly.
- Coordinate with hospitals and third party administrators on cashless cases.
- Catch over billing, unbundled charges and non payable items.
- Raise clear queries only where needed so members are not troubled.
- Decide settlement amounts and record the reasons for any deduction.
- Refer suspicious or unusually large health claims for investigation before settlement.
- Meet the claim turnaround standard while keeping the adjudication accurate and fair.
- Handle member queries on claim decisions with clear explanations.
Requirements
- Graduate in life science, nursing, pharmacy or commerce
- Knowledge of health insurance and medical billing
- A health insurance certification is an advantage
- 1 to 4 years in health claims or a hospital billing desk
KRAs and KPIs for a Health Claims Analyst
Key result areas for the appraisal form, each with a KPI you can measure every month or quarter.
| Key result area | How to measure it |
|---|---|
| Turnaround | Health claims settled within the promised turnaround above target |
| Adjudication accuracy | Claims passing quality audit above the agreed level |
| Leakage control | Non payable and over billed amounts caught against target |
| Query discipline | Avoidable queries to members kept below the agreed level |
| Fraud referral | Suspicious claims referred for investigation on time |
| Member satisfaction | Health claim satisfaction above the agreed benchmark |
Skills and tools
Tools used day to day: Claims management system, Third party administrator portals, Medical coding references, MS Excel, Policy databases.
Reporting line and career path
Next roles: Claims Manager, Health Underwriting Analyst, Quality Auditor Claims
Interview questions for a Health Claims Analyst
- How do you decide what is payable on a hospital bill?
- How do you apply a sub limit or waiting period fairly?
- How do you catch over billing or unbundled charges?
- How do you keep queries to a minimum so members are not troubled?
- How do you handle a cashless case where the hospital overcharges?
- When do you refer a health claim for investigation?
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What does a Health Claims Analyst do?
A Health Claims Analyst adjudicates health insurance claims, deciding what is payable against the policy terms for cashless and reimbursement cases. They check medical bills and treatment details, apply conditions and exclusions, coordinate with hospitals and administrators, catch over billing and settle or query claims fairly and quickly.
What is the difference between cashless and reimbursement health claims?
In a cashless claim the insurer settles the hospital bill directly through a network hospital and administrator, so the member pays little upfront. In reimbursement the member pays the hospital and claims the amount back later with bills. A health claims analyst adjudicates both against the policy terms.
What qualifications does a Health Claims Analyst need?
Most roles ask for a graduate degree, often in life science, nursing, pharmacy or commerce, with a grasp of health insurance and medical billing. A health insurance certification helps. Employers value attention to detail, fairness in applying policy terms, and comfort with medical terminology.