DM-ops- Claims (Thane-Gcorp)

Aditya Birla Health Insurance Company Limited; Maharashtra; On-site; INR 450,000 - 700,000; Full time

Job summary

Aditya Birla Health Insurance Company Limited is seeking a Claims Audit and MIS Coordinator to ensure timely settlement of Travel and OPD claims. You will coordinate with service provider partners, perform medical and technical audits, and maintain comprehensive reports and MIS dashboards.

The role emphasizes accuracy, SLA adherence, and strong Excel/data coordination skills to support monthly/quarterly data submissions and MVP implementations with OPD partners.

Qualifications

• Strong Excel/proficiency for data manipulation and reporting.
• Ability to coordinate cross-functional teams and external partners.
• Experience in data reporting and MIS for claims processes.
• Experience in auditing medical/technical claims.

Responsibilities

• Coordinate with Service provider partner team for timely settlement of Travel and OPD claims.
• Conduct regular medical and technical audits of claims approved for settlement by the partner.
• Maintain MIS/Reports related to claims.
• Submit periodic and ad-hoc reports related to Claims.
• Develop and implement shortcuts or formulas in Excel for timely submission.
• Perform cursory checks before submission.
• Train partner claim processors on policy terms, time management and delegation.
• Coordinate with internal and external stakeholders for data requirements and payments.
• Monitor data/claims dashboards and reports (LDR, daily intimations, monthly MIS for TAT).
• Oversee DN monitoring and ensure compliance with defined controls.

Skills

Excel skills

Coordination skills

Data reporting

Auditing

MIS reporting

Tools

Excel

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

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

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.
• Date of discharge < Date of Admission
• 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

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.