Team Member - Cashless Claims

Aditya Birla Health Insurance Company Limited; Maharashtra; On-site; INR 600,000 - 900,000; Full time

Job summary

Aditya Birla Health Insurance Company Ltd is seeking an Assistant/Deputy Manager - Claims to ensure timely settlement and high-quality audits. The role requires coordination with service provider partner teams, regular medical and technical audits of claims, and maintenance of MIS/reports related to claims.

The position emphasizes achieving SLA/TAT targets, data-driven reporting, and collaboration with internal Departments to improve processes and controls within the Claims domain.

Qualifications

• Experience in health insurance claims processing and audits.
• Ability to maintain MIS / reports related to claims.
• Strong coordination with partner teams and internal departments.

Responsibilities

• Coordinate with service provider partner teams for timely settlement of claims.
• Conduct regular medical and technical audits of approved claims.
• Maintain and analyze MIS/reports related to claims.
• Ensure adherence to SLA/TAT for claim processing.
• Support MVP implementations with partner and tech teams.

Skills

Coordination

Audits

MIS reporting

Excel skills

Data analysis

Tools

Excel

Job description

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

BusinessFinancial Service – HO

UnitAditya Birla Health Insurance Company Ltd

LocationThane

Poornata Position Number of the job Reports to: Poornata Position Number

Poornata Position Title of the job (30 characters max)Assistant/Deputy Manager - ClaimsReports to: Poornata Position TitleManager/ Sr. Manager

FunctionServices OperationsReports to: Function Services Operations

DepartmentClaimsReports to: Department Claims

Designation of the Employee Assistant/Deputy ManagerDesignation of the Manager Manager/ Sr. Manager

Date of writing/updation of JD08.01.2024

• Job Purpose: Write the purpose for which the job exists (in 2-3 lines) (Max 1325 Characters)

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: Mention quantitative or qualitative parameters that are relevant for the job and provide a better understanding of the scope and scale of the job.

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 and Important Parameters for the job: Budgets/ Volumes/No. of Products/Geography/ Markets/ Customers or any other parameter

• Job Context & Major Challenges: Write the specific aspects of the job that provide a challenge (internal and external) to the jobholder in the context of the Business/Unit/Function/Department/Section ((Max 3975 Characters)

To ensure Quality in the claim process and audit, managing TAT as per agreed SLA

• Key Result Areas: Write the key results expected from the job and the supporting actions for each of these key result areas (For a majority of jobs typically there could be 4- 7 key result areas)- Maximum 10 KRAs can be updated

Key Result Areas (Max 1325 Characters) Supporting Actions (Max 1325 Characters) 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 stake holders (internal and external)

Working on DATA / MIS

• Work closely with data teams of external stake holder for reports viz;
• LDR report & monitoring
• Daily intimation reports
• Monthly MIS check - For TAT
• OPD FWA Savings data

DN monitoring for check pts

• Debit note supervision for all the payments from TPA’s & 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
• Policy end date < Policy start date
• Policy start date > Date of Intimation
• Date of Admission should be falling within Policy period
• 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 viz;
• 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

Job Purpose of Direct Reports: Describe the job purpose of the direct report/s to the job (in 2-3 lines for each report)

NA

Relationships: Describe the nature and purpose of most important contacts or relationship (except superior/team members) with individuals, departments, organizations inside and outside of the organization, that job is required to interact with in order to deliver the job objectives

Relationship Type (Max 80 Characters) Frequency Nature (Max 1325 Characters) Internal 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.

SIGN-OFF: Provide the name of the Manager and the jobholder. Signature needed for the hard copy of the JD. Hard copy to be maintained in the organizational record.

Job HolderReports to – Manager

Name

Signature (needed for the hard copy)