Manager - Ops claims ( Hyderabad )

Aditya Birla Capital; Telangana; On-site; INR 900,000 - 1,300,000; Full time

Job summary

Aditya Birla Health Insurance Company Ltd. is seeking an Assistant/Deputy Manager - Claims to oversee settlement coordination with service partners and to perform regular medical and technical audits of settled claims. The role also requires maintaining MIS/reports and ensuring adherence to SLAs.

The ideal candidate will exhibit strong Excel skills, coordination abilities, and proactive problem-solving to support timely claim settlements and data accuracy within the Claims department.

Qualifications

• Regular medical and technical audits of claims.
• Maintain MIS/Reports related to claims.
• Coordinate with partner team for timely settlement.

Responsibilities

• Accurate and timely submission of periodic and ad-hoc reports related to Claims.
• Develop and implement shortcuts and formulae in Excel or alternative tools for timely submission.
• Perform cursory checks before submission and address audit observations.
• Train partner claim processors on policy T&Cs, time management and delegation.
• Coordinate with internal departments and external partners to ensure smooth processing.

Skills

Excel

Coordination

Communication

Attention to detail

Job description

Basic Details

Business: Financial Service – HO

Unit: Aditya Birla Health Insurance Company Ltd

Location: Thane

Poornata Position Number of the job

Reports to: Poornata Position Number

Poornata Position Title of the job (30 characters max): Assistant/Deputy Manager - Claims

Reports to: Poornata Position Title: Manager/ Sr. Manager

Function: Services Operations

Reports to: Function: Services Operations

Department: Claims

Reports to: Department: Claims

Designation of the Employee: Assistant/Deputy Manager

Designation of the Manager: Manager/ Sr. Manager

Date of writing/updation of JD: 08.01.2024

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

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

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

Job Purpose of Direct Reports

NA

Relationships

Describe the nature and purpose of most important contacts or relationship (except superior/team members) with individuals, departments, organizations inside and outside of the organization, that job is required to interact with in order to deliver the job objectives

Relationship Type (Max 80 Characters) Frequency Nature (Max 1325 Characters)

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.

Organizational Relationships

Provide the structure for a level above and below the position for which this job description is written. Use position titles in the structured and indicate all the reports of the position.

SIGN-OFF

Provide the name of the Manager and the jobholder. Signature needed for the hard copy of the JD. Hard copy to be maintained in the organizational record.

Job Holder

Reports to – Manager

Name

Signature (needed for the hard copy)