PHI - Business Solution Specialist - Claims

Prudential Health India; Mumbai; On-site; INR 1,200,000 - 1,600,000; Full time

Job summary

Prudential Health India is seeking a Business Solution Specialist – Claims in Mumbai. The role involves collaborating on new product implementations, managing claims processes powered by data and technology, and ensuring effective communication and negotiation within cross-functional teams. Candidates should have at least 10 years of experience in health insurance and strong analytical skills, thriving in collaborative environments. This position offers an opportunity to contribute significantly to the health insurance landscape in India.

Qualifications

• At least 10 years of experience in health insurance functions, with 3–5 years in health claims insurance.
• End-to-end knowledge of health insurance products and technology systems.
• Proven track record in implementation of significant insurance systems.

Responsibilities

• Collaborate on new product processes, testing, and implementation.
• Implement and manage a customer-centric Claims Management function.
• Conduct process impact analysis and testing collaboratively.

Skills

Health insurance knowledge

Claims management

Analytical skills

Negotiation skills

Creative problem solving

Communication skills

Job description

Overview

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.

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 that processes & technologies are designed to 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.
• 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.
• Check if the current process complies with relevant regulations and industry standards including legal/ compliance/ data privacy.
• 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.
• 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 and 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.
• Coordinate with relevant partners (TPA/Agencies) required for robust digitally‑led claims management process.
• Collaborate with relevant stakeholders, management design and execute staggered plan for ‘Inhouse’ Claims Process setup by Y3.

Qualifications

• Have at least 10 years of total experience in health insurance functions and 3–5 years’ experience in health claims insurance.
• 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 proven track record of end‑to‑end implementation and business outcome delivery of significant insurance systems.
• 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.

What you can do

• Are passionate about consumer behaviour and culture; enjoy spending time with customers to understand what they want and 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 – Claims

Reporting to: Head Underwriting and Claims Management

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.