PHI - Manager- Claims Management

Prudential Health India; Mumbai; On-site; INR 1,000,000 - 1,500,000; Full time

Job summary

Prudential Health India is seeking a Manager for Claims Management in Mumbai. The ideal candidate will guide a processing team and ensure compliance with regulatory guidelines while managing health insurance claims efficiently.

Candidates should have a medical background (MBBS preferred) and extensive experience in claims management. Strong analytical skills and team leadership capabilities are crucial for this role, which aims to enhance the efficiency of claims processing.

Qualifications

• 7–10 years’ experience in health insurance claims management.
• At least 2–3 years in a managerial role.
• Experience in TPA ecosystems is preferred.

Responsibilities

• Guide processing team with medical opinions for claims.
• Ensure compliance with regulatory requirements.
• Manage floor and create rosters for the team.

Skills

Analytical skills

Verbal communication

Team leadership

Negotiation skills

Clinical decision-making

Education

MBBS or equivalent medical degree

Job description

Manager – Claims Management

Join our Experience team in Mumbai.

Key Responsibilities

• Guiding processing team by providing medical opinion for Health Insurance Claims
• Ensuring 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.
• Ensuring compliance with regulatory requirements and implementing them in the claims process.
• Creating detailed standard operating procedures for seamless claims adjudication.
• Case management of potential cases to Network team, maintaining data of referred/saved, impact against cashless outgo.
• Automation and rule‑driven decision making with timely update of benefit in TAT / TMS / Transaction.
• Creating and reviewing claim simplification guidelines to improve TAT and minimize transaction.
• Managing floor – people and SLA (TAT) – create roster, manage adequate manpower on a daily basis, especially on weekends and public holidays.
• Audit of TPA processed claims and also in‑house processed claims.
• Medical decisioning and guidance to the team.
• Analytics and dashboard – preparation to manage TAT, cost vector (ACS, pay‑out ratio), loss ratio, CS:RI ratio and regional distribution.
• Supporting the Group UW team for providing claims analytic input such as specific trend related to FWA, frequency, loss ratio, utilisation of particular benefit.
• Regulatory compliance – claim processing guideline as per compliance and timely implementation of any new circular.
• Litigation cases – claim related to input and evidence in SCN (Self‑containment note) to strengthen our stand in Ombudsman or other legal forum.
• Training TPA teams – timely training for new benefit, process change, understanding and claim philosophy as per PHI standard.
• Benefit claims – processing of benefit claims, creating SOP, pay‑out framework to nominee/legal heir.
• Collaborating 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 the team for indicated cases for Re‑UW referral, tracking and corrective action based on UW decision.
• Extending support to sales/distribution – separate prioritisation queue for green channel, specific agent, broker.
• Setting up and creating robust governance to manage TPA process with great efficiency.
• Proficiency with medical terms & systems (including ICD/CPT/PCS codes).
• Collaborating with Underwriting, Actuarial, Finance and other stakeholders to ensure knowledge sharing on market trends, legal changes and loss developments.

Qualifications

• Doctor by training (MBBS preferred / BAMS / BHMS / BDS).
• 7–10 years’ experience in health insurance claims management with at least 2–3 years’ experience in a manager role.
• Understanding of the TPA ecosystem and experience managing a TPA model (preferred).
• Experience in startup environment or setting up a team from scratch (preferred but not mandatory).
• Decisive & creative individual with good judgment and analytical skills.
• Excellent verbal and written communication skills and strong negotiation skills.
• Open to embracing change and able to manage it.
• Experience managing a team with people from medical and non‑medical background.

Core Competencies

• Passionate about consumer behaviour and culture; enjoy spending time with customers to understand what they truly want.
• Ability to work in a culture where everyone can see what others are doing.
• Willingness to seek help when stuck and to encourage others when there are setbacks.
• Full responsibility for own output while thinking cross‑functionally to solve for the customer.
• Strong clinical knowledge and clinical decision‑making skills.
• Ability to build best‑in‑class processes from scratch.
• Passion for leveraging digital tools to transform customer experience.

Special Qualities

• Read books such as Blue Ocean Strategy & Zero to One.
• Ability to share real stories about how you and your team challenged convention and chose a path less travelled.

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.