AM-Ops Claims(Hyderabad)

Birla Carbon; Hyderabad; On-site; INR 600,000 - 1,000,000; Full time

Job summary

Birla Carbon is seeking an Assistant/Deputy Manager - Claims to manage timely settlements and audits of claims. The ideal candidate will ensure quality in the claim process, develop reports, and maintain communication with internal and external stakeholders.

The role requires strong Excel and coordination skills to train partner claim processors effectively. Responsibilities include regular submission of reports and overseeing data management processes to ensure compliance with company policies.

Qualifications

• Experience in managing timely settlement of claims.
• Ability to conduct regular audits and maintain reports.
• Experience coordinating with multiple stakeholders.

Responsibilities

• Ensure quality in the claim process and audits.
• Develop shortcuts in Excel for timely submission of reports.
• Train partner claim processors on policies and time management.

Skills

Excel Skills

Strong Coordination Skills

Technical Audits

Proactive Approach

Job description

At the Aditya Birla Group, our Corporate Vision is aligned and intricately woven with our People Vision.

Designation: Assistant/Deputy Manager - Claims

Location: India Andhra Pradesh ABHI Begumpet

Business: Aditya Birla Health Insurance Company Ltd

Unit: Thane

Function: Services Operations

Department: Claims

Date of writing/updation of JD: 08.01.2024

1) 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.

2) Dimensions

Business Workforce: On Roll – 6000+; Offroll/ Part time – 4000+

Unit Workforce: On Roll – 6000; Offroll/ Part time – 4000+

Function Workforce: On Roll – 800; Offroll/ Part time – 279

Department Workforce: On Roll – 69; Offroll/ Part time – 66

3) Job Context & Major Challenges

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

4) Key Result Areas

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

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.

Monthly / Quarterly / Annual Data submission

• Work closely with related stakeholders (internal and external)

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

DN monitoring for check points

• Debit note supervision for all the payments from TPA’s & OPD Partners Viz.
• DOA should not be empty
• Future date of admission should not be mentioned
• Date of discharge < Date of Admission
• Policy start date should not be blank
• Policy end date should not be blank
• Policy start date > Date of Intimation
• Date of Admission should be falling within Policy period
• Paid date < DOA

MVP implementations with OPD partners

1. Coordinating with Partner leadership teams / tech teams for MVP implementations viz;
2. FWA triggers implemented in the system (automated)
3. Automated ICD 10 coded data is needed
4. In health check-ups utilization should be driven towards home collection instead of hospitals
5. FWA investigations are to be conducted in the agreed percentage of claims (Partner end)
6. The reimbursement claim adjudication rule engine (automated) should be aligned with the ABHI process
7. Real time client Dashboard for client reviews
8. ABHI to be given system access for claim approval
9. Communication letters in ABHI format
10. Reports and Payment voucher in ABHI format (automated)
11. All fields required in reports to be captured in system for auditing (Debit note to have mandate fields)
12. Query management – under deficiency option should be available
13. Medicos to process OPD claims
14. Data digitization and automated reports to be available
15. API integrations
16. Limits and Sublimits to be defined in the partner system to ensure no over utilization
17. Portal per insured/family should reflect exhausted wallet amount/sub limits and there should be validation in the system to limit utilization up to opted SI
18. Cashless - Portal access end to end
19. Claim Outstanding report (Daily MIS) to be shared
20. Symptom linking prior to slot booking for consultations

5) Job Purpose of Direct Reports

NA

6) 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.