PHI - Business Solution Specialist - Claims

prudential; Mumbai; On-site; INR 2,800,000 - 4,200,000; Full time

Job summary

Prudential Health India (PHI) is seeking a seasoned Business Solution Specialist - Claims in Mumbai to co‑lead the claims function. You will work with Technology, Product, Actuarial, Compliance, and Finance teams to design scalable processes and data‑driven workflows that improve customer experience and control costs.

You will translate high‑level business needs into detailed requirements, own end‑to‑end testing, and drive automation initiatives.

Qualifications

• At least 10 years of total experience in health insurance functions and 3–5 years in Health Claims insurance.
• Ability to understand high‑level processes and translate them into detailed business requirement documents.
• Track record of end‑to‑end implementation and business outcome delivery of significant insurance systems.

Responsibilities

• Collaborate and co-create with cross functional workstreams for new products, processes, testing and implementation.
• Co-create, implement, launch, and manage a customer‑centric Claims Management function/ workflow powered by Data & Technology
• Ensure processes and technologies are designed for automation, scalability and productivity
• Develop in-depth understanding of business processes and create use‑cases, user stories & requirement documents for platforms and projects
• Collaborate with Technology, Product, Actuarial, Claims, Compliance, Risk Management and Finance; represent Claims in Technology & cross‑functional implementations
• Review business process flow diagrams with Business Analysts to ensure comprehensive documentation
• Identify pain points and root causes; ensure compliance with regulations and industry standards
• Lead testing with functional users and prepare test plans and cases
• Enhance rules for allocation, auto adjudication, data masters and fraud triggers in claims management
• Ensure 100% Tariff digitization for empanelment hospitals and preferred networks
• Coordinate with TPAs and agencies for robust digitally led claims management
• Design and execute staggered plan for in-house claims process setup by year 3

Skills

Health insurance

Business analysis

Process improvement

Stakeholder management

Data & Technology

Communication skills

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.

At Prudential Health India (PHI), we are on a mission to make Indians healthier, while bridging the health protection gap. This is a Zero to One team undertaking a greenfield health insurance deployment in India committed to building journeys that will truly empathize with the customer and offer a differentiated, bespoke experience.

To partner us in this mission, we are looking for a talented...

Business Solution Specialist - Claims

As a Business Solution Specialist, your typical week might include the following...

• Collaborate and co-create with cross functional workstreams for new products, processes, testing and implementation.
• Co-create, implement, launch, and manage a customer‑centric Claims Management function/ workflow powered by Data & Technology
• Ensure that processes & technologies are designed focus on automation, scalability, and productivity
• Develop in‑depth understanding of business processes, articulate use‑cases, user‑stories & requirement documents/ change requests for identified features/ capabilities for applicable platforms and projects.
• Collaborate with functions including but not limited to Technology, Product & Actuarial, Claims, Compliance, Risk Management, and Finance; Represent Claims Function in Technology & Cross‑functional implementations
• Review business process flow diagrams with Business Analyst to ensure comprehensive documentation
• a) Identify pain points, bottlenecks, redundancies, delays, errors, or any other areas to enhance the process and dig deeper to uncover the root causes of the identified pain points and inefficiencies
• b) Check if the current process complies with relevant regulations and industry standards including legal/ compliance/ data privacy.
• c) Review techniques such as flowcharts, BPMN diagrams, or process maps to illustrate the sequence of activities, decision points, inputs, outputs, and the roles involved in applicable business processes
• d) Undertake iterations in signed‑off Business Process Flow, when required, in collaboration with stakeholders to refine and finalize the next version.
• Perform process impact analysis across various platforms, holding an end‑to‑end view of user journeys.
• Ensure that acceptance criteria are defined & met; lead testing in collaboration with functional users including jointly preparation & review of test plan, test cases, user acceptance testing.
• Continuous enhancement of Overall Rules for Allocation, Auto Adjudication, Data masters, fraud trigger creation and implementation for claims management process.
• Ensure 100% Tariff digitization for direct empanelment hospitals and preferred network
• Coordination with relevant partners (TPA/Agencies) required for robust digitally led claims management process.
• Collaborate with relevant stake holders, management Design and execute staggered plan for 'Inhouse' Claims Process setup by Y3

You could be the right candidate if you...

• Have atleast 10 years of total experience in health insurance functions and 3-5 years' experience in Health Claims insurance is required.
• Have end-to-end knowledge of health insurance products, operations processes, and technology systems.
• Can understand high‑level processes and can convert them into detailed business requirement documents.
• Have a proven track record of end-to-end implementation and business outcome delivery of significant insurance systems.
• an make informed decisions, swiftly and are adept at creative problem solving; have good judgment and analytical skills
• Have excellent verbal and written communication skills and strong negotiation skills.
• Thrive in environments that celebrate co‑creation and collaboration.
• Have high resilience - can manage yourself, your teams and your peers when faced with ambiguity or failure

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 want. Have an attentive ear to listen to new ideas.
• Join hands with other colleagues to solve for the customer.
• 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 team's contribution output while thinking wing‑to‑wing across the organization.
• Have strong clinical knowledge and clinical decision‑making skills
• Have built best‑in‑class processes from scratch
• Are passionate about leveraging digital tools to transform customer experience

Location: Mumbai

Title: Business Solution Specialist - Clai