Manager- Ops Claims (Thane)

Aditya Birla Capital; Maharashtra; On-site; INR 600,000 - 800,000; Full time

Job summary

Aditya Birla Capital is looking for an Assistant/Deputy Manager - Claims in Thane, Maharashtra. In this role, you will ensure coordination with service provider partners for timely settlement of claims and conduct audits on approved claims. You will manage data reporting and training of partner processors on policies and time management. Ideal candidates should exhibit strong analytical and coordination skills, as well as proficiency in Excel, to meet the demands of this fast-paced role.

Qualifications

• Experience in managing claims processes and audits.
• Strong analytical skills for data and reports.
• Ability to train and coordinate with partner claim processors.

Responsibilities

• Ensure timely settlement of claims with service provider partners.
• Conduct regular audits of claims approved for settlement.
• Manage data submission for reporting purposes.

Skills

Coordination skills

Excel skills

Proactive approach

Sanity checks

Education

Bachelor's degree or higher

Job description

Overview

Basic Details: Fill the required information about business, unit, location, position, reports to position and date of updation of JD

• Business: Financial Service – HO
• Unit: Aditya Birla Health Insurance Company Ltd
• Location: Thane
• Position Title (30 characters max): Assistant/Deputy Manager - Claims
• Reports to: Manager/ Sr. Manager
• Function: Services Operations
• 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 (Max 254 Characters): On Roll – 6000+; Offroll/ Part time – 4000+
• Unit Workforce Number (Max 254 Characters): On Roll – 6000; Offroll/ Part time – 4000+
• Function Workforce Number (Max 254 Characters): On Roll – 800; Offroll/ Part time - 279
• Department Workforce Number (Max 254 Characters): On Roll – 69; Offroll/ Part time - 66
• Other Quantitative Parameters: Budgets/ Volumes/ No. of Products/ Geography/ Markets/ Customers or any other parameter

Key Result Areas

Key Result Areas (KRA) and Supporting Actions (format may be updated to fit needs):

• 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 stakeholders (internal and external)
• Working on DATA / MIS
  • Work closely with data teams of external stake holders for reports viz; LDR report & monitoring, Daily intimations, 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.
  • 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
  • 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
  • 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: 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 format and indicate all the reports of the position.

Sign-off

Job Holder: Reports to – Manager. Signature needed for the hard copy. Signature (needed for the hard copy) on the JD.