DM-OPD Claims (G-corp)

PeopleStrong; Thane; On-site; INR 800,000 - 1,100,000; Full time

Job summary

Aditya Birla Health Insurance Company Ltd in Thane is seeking an Assistant/Deputy Manager - Claims to coordinate with service providers for timely claim settlements and to perform medical and technical audits on claims approved by partners.

The role also requires maintaining MIS reports, ensuring adherence to SLAs, and training partner processors on policy terms and procedures, with a focus on accuracy and timely data submission.

Qualifications

• Role requires coordination with service providers for timely claim settlements.
• Candidate should perform medical and technical audits on approved claims.
• Maintain MIS/reports related to claims and ensure data accuracy.

Responsibilities

• Accurate and timely submission of periodic and ad-hoc reports related to Claims.
• Develop, implement shortcuts and formulas on Excel for timely submissions.
• Perform cursory/sanity checks before submission.
• Closure of audit observations.
• Train partner claim processors on policy terms and time management.
• Coordinate with other departments; maintain proactive communication and strong Excel skills.

Skills

Claims Handling

Job description

BUSINESS_UNIT-2 Claims

Country India

State Maharashtra

Function Services Operations

Skills

Skill

Claims Handling Medical Background

Basic Details:

Business

Unit

Aditya Birla Health Insurance Company Ltd

Location

Thane

Poornata Position Number of the job

Reports to: Poornata Position Number

Poornata Position Title of the job (30 characters max)

Assistant/Deputy Manager - Claims

Reports to: Poornata Position Title

Manager/ Sr. Manager

Function

Services Operations

Reports to: Function

Services Operations

Department

Claims

Reports to: Department

Claims

Designation of the Employee

Assistant/Deputy Manager

Designation of the Manager

Manager/ Sr. Manager

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 Number
(Max 254 Characters)

On Roll – 6000+

Offroll/ Part time – 4000+

Unit Workforce Number
(Max 254 Characters)

On Roll – 6000

Offroll/ Part time – 4000+

Function Workforce Number
(Max 254 Characters)

On Roll – 800

Offroll/ Part time - 279

Department Workforce Number
(Max 254 Characters)

On Roll – 69

Offroll/ Part time - 66

Other Quantitative and Important Parameters for the job: Budgets/ Volumes/No. of Products/Geography/ Markets/ Customers or any other parameter

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 stake holders (internal and external)

Working on DATA / MIS

• Work closely with data teams of external stake holder for reports viz;
• LDR report & monitoring
• Daily intimation reports
• Monthly MIS check - For TAT

DN monitoring for check pts

• 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

• Coordinating with Partner leadership teams /tech teams for MVP implementations viz;

1. FWA triggers implemented in the system (automated)

2. Automated ICD 10 coded data is needed.

3. In health check-ups utilization should be driven towards home collection instead of hospitals.

4. FWA investigations are to be conducted in the agreed percentage of claims.(Partner end)

5. The reimbursement claim adjudication rule engine (automated) should be aligned with the ABHI process.

6. Real time client Dashboard for client reviews.

7. ABHI to be given system access for claim approval

8. Communication letters in ABHI format

9. Reports and Payment voucher in ABHI format (automated)

10. All fields required in reports to be captured in system for auditing (Debit note to have mandate fields)

11. Query management – under deficiency option should be available

12. Medicos to process OPD claims

13. Data digitization and automated reports to be available

14. API integrations

15. Limits and Sublimits to be defined in the partner system to ensure no over utilization

16. 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

17. Cashless - Portal access end to end

18. Claim Outstanding report (Daily MIS) to be shared

19. Symptom linking prior to slot booking for consultations

5) Job Purpose of Direct Reports:

NA

6) Relationships:

Relationship Type (Max 80 Characters)

Frequency

Nature (Max 1325 Characters)

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.