Manager -Ops Claim

Aditya Birla Insulators; Thane; On-site; INR 600,000 - 1,200,000; Full time

Job summary

Aditya Birla Health Insurance Company Ltd in Thane seeks an Assistant/Deputy Manager to coordinate with the service provider partner team for timely settlement of Travel and OPD claims. The role includes medical and technical audits of claims approved for settlement by partners and maintaining MIS/reports related to claims.

You will work within the Claims department, focusing on quality, adherence to SLAs, and data-driven reporting, with responsibilities spanning audits, data submissions, and

Qualifications

• Coordinate with the service provider partner team for timely settlement of Travel and OPD claims.
• Regular medical and technical audits of the claims approved for settlement by the partner.
• Maintain MIS/reports related to claims.

Responsibilities

• Accurate and timely submission of periodic and adhoc reports related to Claims.
• Closure of audit observations.
• Monthly / Quarterly / Annual Data submission.
• Working on DATA / MIS with external stake holders 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 TPAs OPD Partners Viz.
• MVP implementations with OPD partners including automated reporting and system alignment.

Job description

Job Details

Business: Aditya Birla Health Insurance Company Ltd

Location: Thane

Designation of the Employee: Assistant/Deputy Manager

Designation of the Manager: Manager/ Sr. Manager

Function: Services Operations

Department: Claims

Job Summary

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

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

Other Quantitative and Important Parameters for the job: Budgets/ Volumes/ No. of Products/ Geography/ Markets/ Customers or any other parameter

Job Context Major Challenges

To ensure Quality in the claim process and audit, managing TAT as per agreed SLA

Key Result Areas

Write the key results expected from the job and the supporting actions for each of these key result areas (For a majority of jobs typically there could be 4 7 key result areas) Maximum 10 KRAs can be updated

• Accurate and timely submission of periodic and adhoc 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 TC 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;
    1. LDR report monitoring
    2. Daily intimation reports
    3. Monthly MIS check For TAT
    4. OPD FWA Savings data
• DN monitoring for check pts
  • Debit note supervision for all the payments from TPAs OPD Partners Viz.
  1. DOA should not be empty
  2. Future date of admission should not be mentioned.
  3. Date of discharge
  4. Policy start date should not be blank
  5. Policy end date should not be blank
  6. Policy end date
  7. Policy start date > Date of Intimation
  8. Date of Admission should be falling within Policy period
  9. Paid amt> Claimed Amt
  10. Paid date
  11. Paid amt> SI Remarks
• MVP implementations with OPD partners
  • Coordinating with Partner leadership teams /tech teams for MVP implementations viz;
  1. 1. FWA triggers implemented in the system (automated)
  2. 2. Automated ICD 10 coded data is needed.
  3. 3. In health checkups utilization should be driven towards home collection instead of hospitals.
  4. 4. FWA investigations are to be conducted in the agreed percentage of claims. (Partner end)
  5. 5. The reimbursement claim adjudication rule engine (automated) should be aligned with the ABHI process.
  6. 6. Real time client Dashboard for client reviews.
  7. 7. ABHI to be given system access for claim approval
  8. 8. Communication letters in ABHI format
  9. 9. Reports and Payment voucher in ABHI format (automated)
  10. 10. All fields required in reports to be captured in system for auditing (Debit note to have mandate fields)
  11. 11. Query management under deficiency option should be available
  12. 12. Medicos to process OPD claims
  13. 13. Data digitization and automated reports to be available
  14. 14. API integrations
  15. 15. Limits and Sublimits to be defined