Lead - Claims (Thane)

Aditya Birla Capital; Maharashtra; On-site; INR 1,200,000 - 2,100,000; Full time

Job summary

Aditya Birla Health Insurance Co. Limited (ABHICL) invites applications for an MIS specialist to plan, establish and supervise the Claims MIS function, ensuring timely regulatory submissions and audits, and publishing dashboards.

The role requires coordinating with Sales, Finance, Actuary and Internal Claims teams, driving process improvements, automation and accurate data analytics to support decision making.

Qualifications

• Experience in MIS and regulatory submissions for health claims.
• Experience coordinating audits (IRDA, internal, statutory).
• Ability to publish dashboards and analytics for claims trends.

Responsibilities

• Regulatory submissions: timely reports to regulatory authorities.
• Handle audits: IRDA, internal and statutory audits.
• Own audits in Claims; close observations and publish dashboards.
• Produce analytics on claims trends and performance metrics.
• Collaborate with Sales, Finance, Actuary, Underwriting, and Claims teams.

Skills

MIS reporting

Data analysis

Regulatory submissions

Audit coordination

Excel macros

Tools

Excel

Macros

Job description

Job Purpose

The purpose of this role is to plan, establish and supervise the MIS function of Claims. This includes ensuring accurate and timely submission of periodic and ad-hoc reports related to Claims to the Regulatory Authority, handling Audits (IRDA, internal audits and other audits), preparing the claims register, bring in process improvements, automation, publishing analytical reports / Claims MIS and daily dashboard.

The purpose involves Data Support and inter-department coordination with all stakeholders including sales, finance, internal claims and actuary teams.

Key Responsibilities

• Regulatory Submissions: Accurate and timely submission of periodic and ad-hoc reports related to Claims to the Regulatory Authority/GI Council
• Handling Audits - (IRDA, internal audits)
• Complete ownership of handling all audits in the Claims function – IRDA, Internal, Statutory, Concurrent and Retrospective
• Data submission/query response/ad-hoc reports to IRDA/GI Council
• Ensure proper closure of audit observations
• Publish Dashboards
• Claims TATs: Cashless, Reimbursement – in house & TPA periodically
• Analytics – Claims trends and Apprise/Alert the relevant stakeholders
• Publish Daily/weekly/monthly dashboards related to Claims Intimations, TAT, NPS, Settlement Ratio, Average Claim size, Productivity, Pendency, Digital metrics
• Monthly / Quarterly / Annual Data submission
• Coordination – Interdepartmental/within the department
• With internal/external stakeholders including Sales, Finance, Actuary, Underwriting, FWA & Internal claims team – Cashless, Reimbursement, Grievances, Group, Customer Care Team

Job Context & Major Challenges

Write the specific aspects of the job that provide a challenge (internal and external) to the jobholder in the context of the Business/Unit/Function/Department/Section …

About The Health Insurance Industry

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 existing service provider itself. This narrows down the opportunity of the fresh business actually being seriously fought in the market to approximately 1500 odd Crs. With the SME and the start‑ups being the driving force of Indian economy, the opportunity to cater to these segments is immense and is increasing manifold year on year. The challenge here therefore remains as to how we capture a larger share of the opportunity by developing specific solutions to cater each segment of the business. Also by creating an inexpensive and standardised solution to increase the reach into the pockets of channel partners across the country to harness on their captive business and explore new opportunities with them.

Market Opportunities – With the advent of medical advancements, lifestyle changes, change in Indian socio‑economic scenario and Indian healthcare space, and the insurers are facing challenges to cater to the needs of this diverse clientele. Increasingly Indian customers have started considering health insurance partners as extensions of health advisers. In this scenario it becomes extremely important to understand their psyche and then provide tailored solutions with wellness benefits which would help them meet their end objectives and bring in profitable revenue source for the company.

About The Aditya Birla Health Insurance

Aditya Birla Health Insurance Co. Limited (ABHICL) was incorporated in 2015 as a 51:49 joint venture between Aditya Birla Capital Limited (ABCL) and MMI Strategic Investments (Pty) Ltd. ABHICL commenced its operations in October 2016.

ABHICL has entered the competitive health insurance market with an aim to expand the category to wider customer segments, beyond the ones that health insurance companies traditionally have marketed to. As the 6th entrant in a category with well‑established players, ABHICL is creating differentiation and equity for itself though the unique business proposition of “Health Insurance for All”, a one of a kind proposition in India at the moment.

ABHICL’s unique offering to market includes proposition includes -

• A Comprehensive Incentivised 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.
• 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.

Challenges

• To ensure to publish MIS, Regulatory Data submission, Analysis on periodic basis with effective controls built in and allied activities by overcoming system and infrastructure constraints.
• To identify trends, alert and suggest strategies towards risk/fraud mitigation strategies and policies within the framework of Compliance/ Group’s Policies.
• To identify and prevent regulatory breach of Claims TAT’s, and timely data submission by overcoming challenges related to systems and infrastructure, using manual methods where required.

Key Result Areas

Write the key results expected from the job and the supporting actions for each of these key result areas.

• Accurate and timely submission of periodic and ad‑hoc reports related to Claims to the Regulatory Authority/GI Council
• Audits: IRDA, Internal, Stat, others
• Data submission/query response/ad‑hoc reports to IRDA/GI Council
• Closure of audit observations

Supporting Actions

• Develop, Implement shortcuts, macros, formulae on excel, using alternative tools/methods for timely submission
• Develop, train the team, delegate and review their accountability
• Do cursory/sanity checks before submission
• Team training, Time management, Delegation
• Strong coordination skills with other departments, sharp and on the spot thinking, proactive approach, soft skills, excel skills, working with other tools/macros
• Claims TATs: Cashless, Reimbursement – in house & TPA periodically
• Analytics – Claims trends and Apprise/Alert the relevant stakeholders
• Publish Daily/weekly/monthly dashboards related to Claims Intimations, TAT, NPS, Settlement Ratio, Average Claim size, Productivity, Pendency, Digital metrics
• Identify Data sources and do sanity checks
• Work with various tools/develop skills for analysis
• Strong coordination skills with other departments.
• Ensure collation of inputs from various areas and present the same with analysis & findings
• In case of any trends, pattern being observed analyze, investigate and table findings with suggested action areas to the senior management

Monthly / Quarterly / Annual Data submission

Policyholder’s protection committee, Quarterly board meetings, monthly Ops Review, Weekly Claims Review

Job Holder

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