PHI - Assistant Manager- Claims Management

Prudential Health India; Mumbai; On-site; INR 700,000 - 1,000,000; Full time

Job summary

Prudential Health India is seeking an Assistant Manager – TPA Claims Management in Mumbai. The role involves guiding a TPA processing team, overseeing health insurance claims, and ensuring compliance with regulations.

The ideal candidate will have a medical background (BAMS/BHMS/BDS) and experience in health insurance claim processing. You will also need strong decision-making and analytical skills to lead the team effectively.

Qualifications

• 3-5 years of health insurance claim processing management experience.
• 1-2 years as a team leader managing daily claim flow.
• Understanding of the TPA ecosystem.

Responsibilities

• Oversee TPA processing team and provide medical opinions.
• Ensure valid settlements according to company procedures.
• Audit TPA processed claims and in-house claims.

Skills

Health Insurance claims management

Decision-making

Analytical skills

Communication skills

Team leadership

Education

Doctor by training (BAMS/BHMS/BDS)

Tools

Medical coding knowledge (ICD/CPT/PCS)

Job description

Prudential’s purpose is to be partners for every life and protectors for every future. Our purpose encourages everything we do by creating a culture in which diversity is celebrated and inclusion assured, for our people, customers, and partners. We provide a platform for our people to do their best work and make an impact to the business, and we support our people’s career ambitions. We pledge to make Prudential a place where you can Connect, Grow, and Succeed.

Prudential (UK) in partnership with HCL group

Prudential plans to set‑up a standalone Indian health insurance company to address the growing healthcare needs of the Indian consumer. This joint venture will combine Prudential’s global expertise in insurance and financial services with HCL Group’s experience in technology and healthcare solutions. Prudential, with its longstanding presence in India, already operates two leading businesses in life insurance and asset management with the ICICI Group. Prudential was also the proud sponsor of the 1983 Cricket World Cup, India’s first World Cup Victory!

Assistant Manager – TPA Claims Management

As an Assistant Manager Claims, your typical week might include the following:

• Guiding TPA processing team by providing medical opinion for Health Insurance Claims
• Ensure claims of valid settlements are made according to the company practice and procedures.
• Processing and approving medical claims pertaining to Indemnity, Benefit for both Group and Retail, with sharp FWA and Loss minimization approaches.
• Thorough on the compliance and regulatory requirements and implementation in the claims process.
• Case management of potential cases to Network team, maintaining data of referred/saving achieved/impact against cashless outgo.
• Automation and rule driven decision making with timely update of benefit in TAT / TMS / Transaction
• Create and reviewing claim simplification guidelines to Improve TAT, Minimize transaction.
• Medical decisioning and guidance to the team
• Audit of TPA processed claims and also Inhouse processed claims.
• Regulatory compliances – Claim processing guideline as per compliance and timely implementation of any New Circular.
• Train TPA teams – Timely Training of TPA for new benefit, process change, Understanding and claim Philosophy as per PHI standard.
• Benefit claims – Well versed with processing of Benefit claims, Creating SOP, Pay‑out framework to Nominee/Legal heir.
• Collaborate with FWA Manager to provide inputs from agencies for efficient Fraud restriction and necessary checks and balances in system.
• Re‑UW opinion for non‑disclosure cases – Training to Team for indicated cases for Re‑UW referral, tracking and corrective action basis UW decision.
• Extend support to the sales/distribution – Separate prioritization que for green channel, Specific Agent, Broker.
• Set up and create robust governance to manage TPA process with great efficiency.
• Proficient with medical terms & systems (including ICD/CPT/PCS codes).

You could be the right candidate if you…

• Are a doctor by training (/BAMS/BHMS/BDS)
• Have 03‑05 years’ experience of health Insurance claim processing management with at least 1‑2 years’ experience as team leader managing and holding responsibility daily claim flow.
• Understands the TPA ecosystem and has experience of managing TPA model (Preferred)
• Have startup experience or setting up a team from scratch (Preferred but not mandatory)
• Should be a decisive & creative individual.
• Should be able to make quick decisions and have good judgment and analytical skills
• Have an excellent verbal and written communication skills and strong negotiation skills.
• Always open to embracing change and be able to manage it

This could be the gig for you if you…

• Are passionate about consumer behaviour and culture; enjoy spending time with customers to understand what they really want. Have an attentive ear listen to new ideas.
• Like to work in a culture where everyone can see what others are doing
• Take help from others when stuck and encourage others when there are setbacks
• Take full responsibility for your own output while thinking wing to wing across the organization; to solve for the customer
• Have strong clinical knowledge and clinical decision‑making skills
• Have built best in class processes from a scratch.
• Are passionate about leveraging digital tools to transform customer experience

What Can Make You Extra Special

• It’s great if you have already read books like Blue Ocean strategy & Zero to 1. Before you saw them mentioned here.
• You have real stories to tell about how your team, and you challenged convention and took the path less travelled.
• We are keen to listen to your story; doesn’t matter if you tell these stories with a sigh or with excitement. We respect both versions. Truly.

Location: Mumbai

Prudential is an equal opportunity employer. We provide equality of opportunity of benefits for all who apply and who perform work for our organisation irrespective of sex, race, age, ethnic origin, educational, social and cultural background, marital status, pregnancy and maternity, religion or belief, disability or part‑time / fixed‑term work, or any other status protected by applicable law. We encourage the same standards from our recruitment and third‑party suppliers taking into account the context of grade, job and location. We also allow for reasonable adjustments to support people with individual physical or mental health requirements.