Team Member- Claim Control (G-corp)

Birla Carbon; Thane; On-site; INR 600,000 - 800,000; Full time

Job summary

Birla Carbon is looking for a Team Member in Claims Control to establish a robust framework ensuring compliance and risk mitigation. The role involves implementing governance through audits and leveraging analytics for actionable insights.

Focus areas include continuous process improvement, adherence to industry standards, and engaging in effective claims management strategies within the health insurance sector.

Qualifications

• Experience in establishing claims control frameworks.
• Knowledge of IRDAI regulations and compliance.
• Strong analytical skills and proficiency in SQL.

Responsibilities

• Implement end-to-end claims control frameworks.
• Ensure adherence to regulatory guidelines.
• Conduct periodic audits and identify risk indicators.
• Drive process improvements and system enhancements.

Skills

Regulatory compliance

Audit processes

Analytics

SQL

Process automation

Education

Bachelor's degree in relevant field

Tools

Excel

Dashboards

Job description

Role Title

Team Member – Claims Control

Job Purpose

The role is responsible for establishing and maintaining a robust claims control framework that ensures regulatory compliance, quality assurance, and risk mitigation across the claims process. It drives governance through audits, fraud prevention, and leakage control, while leveraging MIS, analytics, and dashboards to provide actionable insights. The position also focuses on continuous process improvement and automation, enabling efficiency, transparency, and adherence to industry standards in claims management.

Job Context & Major Challenges

About the Health Insurance Industry – The market is dominated by a few major players, with a significant share of business renewing with existing providers. Capturing new business opportunities in segments such as SME and start‑ups is a key challenge. Market dynamics, evolving customer expectations, and the need for wellness‑focused, technology‑enabled solutions add further complexity to the role. Aditya Birla Health Insurance Co. Ltd aims to differentiate itself with a unique business proposition – a comprehensive wellness program, chronic care management, a digital, paperless approach, and strong analytical capabilities to support timely MIS and regulatory data submission.

Key Result Areas

• Claims Control Framework & Governance – Implement end‑to‑end claim control frameworks, SOPs, checklists, and monitoring mechanisms.
• Regulatory & Compliance Adherence – Ensure adherence to IRDAI regulations, TAT norms, policy wording and internal guidelines.
• Claims Quality & Risk Reviews – Conduct periodic claim quality audits, high‑value claim reviews and exception analysis; identify risk indicators, trends and root causes; recommend preventive and detective controls; develop control MIS, dashboards and analytical reports using Excel, SQL or other tools.
• Process Improvement & Automation – Identify control gaps and drive process simplification, automation and system enhancements.