Lead OPD Claims

PeopleStrong; Maharashtra; On-site; INR 900,000 - 1,500,000; Full time

Job summary

Aditya Birla Health Insurance is seeking a provider network professional to build and manage a regional network of hospitals, clinicians, and care providers. You will own end-to-end relationships, drive access to high-quality, cost-effective healthcare for customers, and ensure timely delivery of services.

This role requires strong negotiation with providers, alignment with Customer Services and Operations, and the ability to design and monitor contracts, CMS/claims processes, and KPIs across

Qualifications

• Experience building and managing a provider network within a defined region.
• Ability to negotiate and manage provider contracts to balance quality and cost.
• Strong collaboration with Customer Services and Operations teams.

Responsibilities

• Own end-to-end relationships with allocated providers in region.
• Negotiate commercial contracts and renewals with providers.
• Collaborate with internal teams to deliver high-value, quality services.

Skills

Provider network management

Contract negotiation

Stakeholder coordination

Tools

CRM systems

Job description

CERTIFICATION

Job Description

Job Purpose

The job holder is a key member of a team, responsible for creating and managing Aditya Birla health Insurance network of hospitals, clinicians and other healthcare providers within a defined geographical region, ensuring customers are able to readily access high quality, cost effective, customer focused healthcare when they need it. The team is charged with the development, maintenance and management of a recognised provider network within its allocated region.

The job holder will own the end-to end relationship with allocated healthcare providers within their geographical region. This will include the negotiation and management of new and existing provider contracts to improve the quality and value of services available to Aditya Birla customers including cashless direct settlement.

The job holder will work closely with the rest of the Customer Services and Operations team, and across the business to ensure the timely delivery of high value, high quality services to Aditya Birla's customers.

Job Context & Challenges

Job Context & Challenges:

Challenges -

Distribution: How we create specific distribution models to penetrate different market segments remains a challenge. Motivation to channel partners to place business with the co. Activate and manage agent based distribution channel across the country

Long term and short term strategic plans to increase the market share and profitability in line with the company's business objectives.

Identifying new segments, structure offerings, and value enhancers apart from creating differentiators' remains a big challenge for the company's growth. Meeting varied client's expectation in terms of solutions, pricing and operational support remains a challenge.

Build and further enhance relationships with key customers and partners alike.

Build the vertical in line with the leadership teams expectation of having the group benefits team contributing substantially to the bottom-line in years to come

Key Challenges for the role -

• Business Challenges: The strategy adopted by the market participants in order to actively and aggressively source business has a key impact on the market dynamics. While there have been service providers who have remained consistently focussed on the risk business, there have been other players who have adopted a very aggressive. Hence how we fare in the market also gets influenced by what strategy these participants pursue.
• Soft Insurance Market: Considering the soft insurance market in India, offering solutions to price sensitive clients may turn risky. Such clients may negotiate hard on the unique solution offered which eats away the cos profitability and may opt to place the business with other manufacturers. It is extremely important to design and customize the right solution for the right set of clients.
• Lack of historical data: Data based analytics is possible for players having historical data and in business for years. At the onset opportunity identification needs to be done basis feedback from partners, clients and experience. The decision to pursue an opportunity might not always be backed by data.
• Inter departmental challenges: Offering and structuring a deal often involves working with various departments like operations, claims, actuarial etc to see what best can be offered. There may be instances that actuarial may not be comfortable offering a particular price that has been made available to the customer and hence working with them to see how best can things be modulated is often a tough ask. Also getting various stakeholders and constituents to the process like operations to understand the sensitivities of the various partners involved and seeing the creation of a process which meets our objective without offending either the partner concerned or the internal norms gets to be a challenge that has to be fought on a daily basis.
• Partners: Given that close to 90 percent of the activity in terms of the deals coming in the market to be fought are from our partners, working with them in terms of structuring their payouts gets to be a challenge. There are peers in the market who adopt aggressive payout strategies whether it be a new business or it be a renewal and have a faster turn-around process for the same to be remitted. Besides this, they keep doing off-sites at local levels for the team players and hence that gets them a marginal head start. Hence these factors have to be taken into account and managed accordingly. How we build a scenario with partners where they start to look at us as a longer duration partnership and work in progress and not just as a transaction basis remains a key. Similarly building a relationship with partners to constantly seek insights on what the competition is upto and also what are some of the new thoughts that can be pursued is a key challenge that needs to be pursued.

Key Result Areas

KRA (Accountabilities) (Max 1325 Characters)

Supporting Actions (Max 1325 Characters)

KRA1 Contribute to the implementation, development and maintenance of Aditya Birla's provider strategy within an allocated region 1. Contribute to the implementation, development and maintenance of Aditya Birla's provider strategy within an allocated region, ensuring alignment with Aditya Birla's overall business strategy and provider strategy. 2. Negotiate appropriate commercial contracts and renewals with allocated providers in a timely manner to allow customers access to quality healthcare at sustainable cost structures and rates. 3. Using standard funding models and fee structures negotiate commercial deals on the best possible terms for Aditya Birla, including risk sharing with providers. 4. Own the relationship with allocated providers, including regular review and monitoring of KPIs, review meetings, escalation point for issues, etc. 5. In collaboration with Provider Contracts Manager, research availability and quality of healthcare provision in allocated region, including opportunities where new capacity is being developed. 6. Develop and extend the network to give wider geographical and provider coverage (eg diagnostic centres, speciality centres, doctors, etc) as required by the Provider Contracts Manager.

KRA2 Contribute to the implementation, development and maintenance of Aditya Birla's provider strategy within an allocated region 7. Form effective working relationships with key internal stakeholders in Aditya Birla, and within Aditya Birla Group and MMI Group where appropriate. 8. Pro-actively support, advice and coach providers to strengthen relationships and manage costs. 9. Obtain feedback and recommendations from providers and disseminate to the relevant Customer Service and Operations departments to improve levels of service to customers. 10. Regularly review and monitor data including claims volumes, spend procedure volumes, and provider behaviour to ensure that opportunities for claims spend savings are highlighted. 11. To understand, comply with and abide by the regulatory requirements. 12. Responsible for TPA relationship management across India and provide monthly, quarterly reconciliation reports and SLA adherence 13. Lead in TPA audit and recovery process from Provider Contracts team.