TM-Ops Claims (Thane)

Birla Carbon; Thane; On-site; INR 800,000 - 1,400,000; Full time

Job summary

The Medical Claims Processor – PreAuth operates in a high-volume, time-sensitive environment where prompt and accurate claim decisions directly impact customer experience and healthcare service delivery.

The role requires evaluating pre-authorization requests from hospitals by reviewing policy coverage, medical documentation, treatment necessity, exclusions, waiting periods, and claim eligibility while meeting defined turnaround times.

Job description

At the Aditya Birla Group, our Corporate Vision is aligned and intricately woven with our People Vision.

TM-Ops Claims (Thane)

Designation : Manager

Job Description:

Business: Aditya Birla Health Insurance Company Ltd

Location: Thane

Poornata Position Title of the job: Assistant/Deputy Manager - Claims

Reports to: Manager/ Sr. Manager

Function: Services Operations

Department: Claims

Designation of the Employee: Assistant/Deputy Manager/ Manager

Designation of the Manager: Manager/ Sr. Manager/ DCM/ CM

Date of writing/updation of JD: 08.01.2024

The Medical Claims Processor – PreAuth is responsible for the accurate and timely assessment, processing, and authorization of cashless hospitalization requests in accordance with policy terms, medical guidelines, and company procedures. The role ensures adherence to service level agreements (SLAs), quality standards, and regulatory requirements while delivering an excellent customer experience.

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

The Medical Claims Processor – PreAuth operates in a high-volume, time-sensitive environment where prompt and accurate claim decisions directly impact customer experience and healthcare service delivery. The role requires evaluation of pre-authorization requests received from hospitals by reviewing policy coverage, medical documentation, treatment necessity, exclusions, waiting periods, and claim eligibility while adhering to defined turnaround times (TATs) and quality standards.

The key challenge is balancing speed with accuracy, as authorization decisions must be made within stringent SLA timelines without compromising on quality, compliance, or risk management. The incumbent is required to coordinate with hospitals, medical teams, customers, and internal stakeholders to obtain complete and

The role also involves handling reimbursement/Pre Auth/ Retail/Group medical cases, incomplete documentation, treatment justification reviews, policy interpretation issues, and escalations from hospitals or customers. Ensuring compliance with organizational policies, regulatory requirements, fraud control measures, and audit standards while maintaining productivity and service quality is a critical aspect of the position.

• Managing high volumes of all types of claims (retail/group) requests within defined TATs.
• Ensuring accurate claim decisions while minimizing operational and financial risk.
• Reviewing all levels of medical cases and treatment protocols.
• Handling incomplete or inadequate documentation from hospitals.
• Managing customer and hospital expectations during urgent hospitalization cases.
• Identifying potential fraud, abuse, and policy misuse.
• Maintaining quality scores, audit compliance, and productivity targets simultaneously.
• Coordinating effectively with medical experts, hospitals, TPAs, and internal functions for timely claim resolution.
• Keeping abreast of policy updates, medical advancements, and regulatory changes impacting claim adjudication.

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

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 start date > Date of Intimation
• Date of Admission should be falling within Policy period
• Paid date < DOA

MVP implementations with OPD partners

• Coordinating with Partner leadership teams /tech teams for MVP implementations viz;

1. FWA triggers implemented in the system (automated)

2. Automated ICD 10 coded data is needed.

3. In health check-ups utilization should be driven towards home collection instead of hospitals.

4. FWA investigations are to be conducted in the agreed percentage of claims.(Partner end)

5. The reimbursement claim adjudication rule engine (automated) should be aligned with the ABHI process.

6. Real time client Dashboard for client reviews.

7. ABHI to be given system access for claim approval

8. Communication letters in ABHI format

9. Reports and Payment voucher in ABHI format (automated)

10. All fields required in reports to be captured in system for auditing (Debit note to have mandate fields)

11. Query management – under deficiency option should be available

12. Medicos to process OPD claims

13. Data digitization and automated reports to be available

14. API integrations

15. Limits and Sublimits to be defined in the partner system to ensure no over utilization

16. 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

17. Cashless - Portal access end to end

18. Claim Outstanding report (Daily MIS) to be shared

19. Symptom linking prior to slot booking for consultations

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.

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