DM-Ops-Claims (Hyderabad )

Aditya Birla Health Insurance Company Limited; Telangana; On-site; INR 350,000 - 520,000; Full time

Job summary

Aditya Birla Health Insurance Company Limited is seeking a Claims professional responsible for settlement of cashless indemnity claims and adherence to set guidelines. The role involves monitoring team performance, maintaining TAT, and ensuring compliance with insurance laws and health product terms.

The incumbent will participate in process improvements, training programs, and periodic portfolio analysis to sustain client satisfaction and control losses.

Qualifications

• Experience in processing health insurance claims and understanding cashless/indemnity workflows.
• Familiarity with Insurance Law, health products and medical terminology.
• Ability to monitor team performance and ensure adherence to TAT and guidelines.

Responsibilities

• Process and monitor cashless indemnity claims for assigned verticals.
• Track and report claims performance metrics and TATs.
• Provide training and empowerment guidance to Claims Officers.
• Review and compare claims guidelines with competition; suggest changes as needed.

Skills

Claims processing

Insurance guidelines

Fraud awareness

Healthcare terms

TPA knowledge

Quality monitoring

Tools

Claims systems

Job description

Job Purpose

The role is responsible for settlement of all claims for assigned verticals & to either process or repudiate as per set guidelines and close within defined TAT.

Job Context & Major Challenges

Job Context & Challenges:While the current market sees more than 15 non-life players in the private space and 5 exclusive private players in the health insurance space trying to capture a sizable market share, the nationalized service provider (6) remains a strong competitor. In addition to this the business dynamics are such that the overall market on an annual basis which is to the tune of roughly 10,000 Crs sees close to 85 % of the business renewing with the ABHI,s unique offering to market includes proposition includes -

• A Comprehensive Incentivized Wellness Program that will attract the young and health conscious and will motivate, guide and reward them to stay healthy
• A Chronic Care Management Program to cater to the unmet needs of a growing Indian population of those suffering from chronic lifestyle conditions like Diabetes, Asthma, High Cholesterol and Hypertension from Day 1

ABHICL serves as an enabler and influencer of health and healthcare choices that customers make, in addition to being a payer of healthcare expenses. Thus, ABHICL would act like a much needed catalyst to grow the prevalent health insurance landscape in India through product innovations and a wider choice of consumer relevant products.

ABHICL,s vision has always been digital. The company has been successful in adopting paper-less approach right from identifying to on-boarding to delivering seamless experience of its customers & employees.

Create, monitor and improve Innovative Claim Processes, SOPs, Protocols & implement the same for Claims Processed through In-house Team as well as Claims Processed through Partner TPAs

Ensuring that the team members are up-to speed in a short time frame and enhancing their Skills by Periodic Functional & Product Training Programs

System development & UAT, Claims: Indemnity & Fixed Benefit Products (Retail & Group)

Expectations management of the Claims team & TAT & expectations management for specialized business handling.

Claims decisions in adherence & compliance with the Claims guidelines, uniformity in decisions, and approval authority limits (In house and TPA claims)

Periodic Portfolio analysis & Maintain a consistent service delivery to ensure client retention and satisfaction

Minimise Loss Ratio & Monitor the Profitability of Portfolio

Key Result Areas

KRA1 Processing & Monitoring of Cashless Indemnity Claims

1. Cashless Management

• Appropriate & timely resolution of escalations
• Monitor Claims Team Performance metrics
• Measure Claims decisions: Quality & cashless TAT
• Retrospective Claims Quality Analysis
• Analyzing claims trends across various channels and providing feedback and recommendations to claims and underwriting via calling Intelligence
• Team Management
• Claim Ration
• Management of Fraud and Abuses
• Process Improvement
• Knowledge of Insurance Law / Health products / Medical terms

KRA2 Monitor Claims Team Performance metrics

Monitor Claims transactions, authority limits, TATs

Appropriate & timely resolution of escalations

Measure Claims decisions: Quality & TAT (in House & TPA processed Claims)

Review of o/s Claims

KRA3 Recommend empowerment for Claims Officers Audit

Training

KRA4 Review the Claims guidelines v/s competition

Analyze business trends, recommend changes if any.

Perform cost benefit analysis.