TM-Ops-Claims(Thane ) professional

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

Job summary

Aditya Birla Insulators in Thane is seeking a Claims Audit and MIS Analyst to coordinate with the service provider partner team for timely settlement of Travel and OPD claims. The role conducts regular medical and technical audits of approved claims and maintains comprehensive MIS reports.

You will work with internal and external stakeholders to ensure data accuracy, monitor SLA/TAT, and drive improvements through Excel-based analytics and process trainings for partner claim processors.

Qualifications

• Strong Excel skills and ability to develop MIS reports.
• Experience in auditing travel and OPD claims.
• Excellent coordination and communication with internal/external teams.

Responsibilities

• Prepare periodic and ad hoc reports related to claims.
• Perform regular audits of claims approved for settlement by the partner.
• Maintain MIS/Reports related to claims.
• Ensure timely submission and accuracy of data; monitor SLA/TAT.
• Coordinate with service provider partner teams for settlements.
• Address audit observations with trainings and follow-ups.

Skills

Excel proficiency

Data analysis

Auditing

Coordination

Communication

Tools

Excel

Job description

Job Summary

The job purpose 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

• Business Workforce Number: On Roll 6000+, Offroll 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

Job Context & Major Challenges

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

Key Result Areas

• Accurate and timely submission of periodic and adhoc 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.

1. DOA should not be empty
2. Future date of admission should not be mentioned.
3. Date of discharge
4. Policy start date should not be blank
5. Policy end date should not be blank
6. Policy end date
7. Policy start date > Date of Intimation
8. Date of Admission should be falling within Policy period
9. Paid amt > Claimed Amt
10. Paid date
11. Paid amt > SI Remarks

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 checkups 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

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