TM-Ops-Claims(Thane )

Birla Carbon; Thane; On-site; INR 600,000 - 1,200,000; Full time

Job summary

Aditya Birla Health Insurance Company Ltd. in Thane seeks an Assistant/Deputy Manager - Claims to oversee timely settlement of travel and OPD claims, perform regular medical and technical audits, and maintain comprehensive MIS dashboards.

The role requires strong Excel skills, data-driven mindset, and effective coordination with internal teams and external partners. The incumbent will ensure SLA adherence, manage data submissions, and drive automated reporting initiatives with MVP

Qualifications

• Must coordinate with partner teams to ensure timely settlement of claims
• Regular medical and technical audits of claims approved for settlement
• Maintain MIS/reports related to claims and support data-driven decisions
• Strong Excel skills and ability to develop shortcuts/ formulae for timely submission
• Capability to train partner processors on policy terms and timelines

Responsibilities

• 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&Cs, Time management, Delegation
• Strong coordination with other departments and stakeholders
• Monthly/Quarterly/Annual data submission
• Work closely with data teams of external stakeholders for reports (e.g., LDR, Daily MIS, Monthly MIS)
• Data management and dashboards for claim processes
• API integrations and data standardization with partners
• ABHI-format communications, reports, and vouchers
• All required fields captured in system for auditing

Skills

Coordination

Audit

MIS

Data analysis

Excel

Time management

Delegation

Soft skills

Policy T&C knowledge

APIs

Tools

APIs

Job description

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

Job Description:

Basic Details:

Business

Unit

Aditya Birla Health Insurance Company Ltd

Location

Thane

Poornata Position Number of the job

Reports to: Poornata Position Number

Poornata Position Title of the job (30 characters max)

Assistant/Deputy Manager - Claims

Reports to: Poornata Position Title

Manager/ Sr. Manager

Function

Services Operations

Reports to: Function

Services Operations

Department

Claims

Reports to: Department

Claims

Designation of the Employee

Assistant/Deputy Manager

Designation of the Manager

Manager/ Sr. Manager

Date of writing/updation of JD

08.01.2024

1) Job Purpose:

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.

2) Dimensions:

Business Workforce Number

On Roll – 6000+

Offroll/ Part time – 4000+

Unit Workforce Number

On Roll – 6000

Offroll/ Part time – 4000+

Function Workforce Number

On Roll – 800

Offroll/ Part time - 279

Department Workforce Number

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

3) Job Context & Major Challenges:

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

4) Key Result Areas:

Key Result Areas (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

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

5) Job Purpose of Direct Reports:

NA

6) Relationships:

Relationship Type:

Frequency:

Nature:

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.

7) Organizational Relationships:

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