AM-Ops-claims (Hyderabad)

Birla Carbon; Hyderabad; On-site; INR 500,000 - 800,000; Full time

Job summary

Birla Carbon in Hyderabad is looking for a professional to coordinate with service provider partners for timely settlement of Travel and OPD claims. The role involves conducting audits and maintaining reports related to claims.

Ideal candidates will have strong Excel skills, coordination capabilities, and experience in claims processing. The position requires proactive communication and a focus on quality assurance across various stakeholders.

Qualifications

• Experience in claim processing and audits.
• Knowledge of Medical Information Systems/MIS.
• Ability to conduct training for partners.

Responsibilities

• Coordinate with service providers for claim settlements.
• Prepare periodic and ad-hoc reports related to claims.
• Ensure quality control in the claims process.

Skills

Excel skills

Strong coordination skills

Proactive approach

Soft skills

Education

Bachelor's degree or equivalent

Job description

Job Purpose

The purpose of this role includes ensuring coordination with the Service provider partner team for timely settlement of Travel and OPD claims. Candidate should be able to do regular medical and technical audits of the claims approved for settlement by the partner and should be able to maintain the MIS/Reports related to claims.

Dimensions

• Business Workforce Number: On Roll – 6000+, Offroll/Part time – 4000+
• Unit Workforce Number: On Roll – 6000, Offroll/Part time – 4000+
• Function Workforce Number: On Roll – 800, Offroll/Part time – 279
• Department Workforce Number: On Roll – 69, Offroll/Part time – 66

Job Context & Major Challenges

To ensure Quality in the claim process and audit, managing TAT as per agreed SLA.

Key Result Areas

1. Accurate and timely submission of periodic and ad-hoc reports related to Claims

• Develop, implement shortcuts, formulae on Excel, using alternative tools/methods for timely submission.
• Do cursory/sanity checks before submission.

2. Closure of audit observations

• Trainings to the partner claim processors regarding policy T&C’s, time management, delegation.
• Strong coordination skills with other departments, sharp and on the spot thinking, proactive approach, soft skills, Excel skills etc.

3. Monthly / Quarterly / Annual Data submission

• Work closely with related stakeholders (internal and external).

4. Working on DATA / MIS

• Work closely with data teams of external stakeholders for reports viz;
• LDR report & monitoring.
• Daily intimation reports.
• Monthly MIS check – for TAT.

5. DN monitoring for checkpoints

• Debit note supervision for all payments from TPAs & OPD partners.
• DOA should not be empty.
• Future date of admission should not be mentioned.
• Date of discharge $lt$ Date of Admission.
• Policy start date should not be blank.
• Policy end date should not be blank.
• Policy start date $gt$ Date of Intimation.
• Date of Admission should fall within policy period.
• Paid date $lt$ DOA.

6. MVP implementations with OPD partners

• Coordinating with partner leadership teams / tech teams for MVP implementations viz;
• FWA triggers implemented in the system (automated).
• Automated ICD 10 coded data is needed.
• In health check-ups utilisation should be driven towards home collection instead of hospitals.
• FWA investigations are to be conducted in the agreed percentage of claims (partner end).
• The reimbursement claim adjudication rule engine (automated) should be aligned with the ABHI process.
• Real‑time client dashboard for client reviews.
• ABHI to be given system access for claim approval.
• Communication letters in ABHI format.
• Reports and payment voucher in ABHI format (automated).
• All fields required in reports to be captured in system for auditing (debit note to have mandatory fields).
• Query management – under deficiency option should be available.
• Medicos to process OPD claims.
• Data digitization and automated reports to be available.
• API integrations.
• Limits and sublimits to be defined in the partner system to ensure no over utilisation.
• Portal per insured/family should reflect exhausted wallet amount/sub limits and there should be validation in the system to limit utilisation up to opted SI.
• Cashless – portal access end to end.
• Claim outstanding report (daily MIS) to be shared.
• Symptom linking prior to slot booking for consultations.

Relationships

Internal

• Internal (MIS Team)
• Ongoing
• To coordinate and collate the data requirement. Coordinate with MIS template for processing payments of the partner.

External

• External Partners (Service providers)
• As and when required
• To decide on claims, reconsideration claims and claims beyond the authority of the partner processing team, developments/ enhancements.