DM-Ops Claim( Thane)

Aditya Birla Health Insurance Company Limited; Maharashtra; On-site; INR 350,000 - 550,000; Full time

Job summary

Aditya Birla Health Insurance Company Ltd in Thane seeks an Assistant/Deputy Manager - Claims to oversee medical claims processing and pre-authorization workflows. You will ensure accuracy, timely decisions, and adherence to SLAs while coordinating with hospitals, TPAs, and internal teams.

The role demands strong analytical skills, attention to detail, and ability to manage high volumes with regulatory compliance. A customer-focused approach is essential to balance service quality with control.

Responsibilities

• Accurate and timely assessment, processing, and authorization of cashless hospitalization requests.
• Ensure compliance with policy terms, medical guidelines, and SLAs.
• Coordinate with hospitals, TPAs, and internal teams for timely resolutions.

Job description

Business

Financial Service – HO

Unit

Aditya Birla Health Insurance Company Ltd

Location

Thane

Assistant/Deputy Manager - Claims

Reports to: Manager/ Sr. Manager

Function

Services Operations

Department

Claims

Designation of the Employee

Assistant/Deputy Manager/ Manager

Designation of the Manager

Manager/ Sr. Manager/ DCM/ CM

Date of writing/updation of JD

08.01.2024

The Medical Claims Processor – PreAuth is responsible for the accurate and timely assessment, processing, and authorization of cashless hospitalization requests in accordance with policy terms, medical guidelines, and company procedures. The role ensures adherence to service level agreements (SLAs), quality standards, and regulatory requirements while delivering an excellent customer experience.

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

Major Challenges

• Managing high volumes of all types of claims (retail/group) requests within defined TATs.
• Ensuring accurate claim decisions while minimizing operational and financial risk.
• Reviewing all levels of medical cases and treatment protocols.
• Handling incomplete or inadequate documentation from hospitals.
• Managing customer and hospital expectations during urgent hospitalization cases.
• Identifying potential fraud, abuse, and policy misuse.
• Maintaining quality scores, audit compliance, and productivity targets simultaneously.
• Coordinating effectively with medical experts, hospitals, TPAs, and internal functions for timely claim resolution.
• Keeping abreast of policy updates, medical advancements, and regulatory changes impacting claim adjudication.

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
• OPD FWA Savings data
• 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.
• Policy start date should not be blank
• Policy end date should not be blank
• Policy end date < Policy start date
• Policy start date > Date of Intimation
• Date of Admission should be falling within Policy period
• Paid amt>Claimed Amt
• Paid date
• Paid amt>SI Remarks

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 utilization 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 mandate 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 utilization
• 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
• Cashless - Portal access end to end
• Claim Outstanding report (Daily MIS) to be shared
• Symptom linking prior to slot booking for consultations

NA (individual contributor role)

• Relationships: Describe the nature and purpose of most important contacts or relationship (except superior/team members) with individuals, departments, organizations inside and outside of the organization, that job is required to interact with in order to deliver the job objectives

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.

• Organizational Relationships: Provide the structure for a level above and below the position for which this job description is written. Use position titles in the structured and indicate all the reports of the position.