TM-Reimbursement Claims Professional

Aditya Birla Insulators; Thane; On-site; INR 600,000 - 900,000; Full time

Job summary

Aditya Birla Insulators seeks a data and MIS specialist to coordinate with service provider teams for timely settlement of Travel and OPD claims. The role involves regular medical and technical audits of approved claims and maintenance of MIS/reports related to claims.

The position emphasizes accuracy, timely submissions, and collaboration with internal and external stakeholders to ensure SLA adherence and proper data governance.

Qualifications

• Proficient in Excel for data analysis and reporting.
• Experience in MIS and data validation.
• Ability to coordinate with service provider teams and claim handlers.

Responsibilities

• Accurate and timely submission of periodic and ad-hoc reports related to claims.
• Develop shortcuts and formulas in Excel to enable timely submissions.
• Perform cursory checks before submission to ensure accuracy.
• Close audit observations and train partner claim processors on policy terms and time management.
• Coordinate with internal and external stakeholders for monthly/quarterly data submissions.
• Work with data teams of external partners for reports such as LDR, daily intimations, and monthly MIS checks.
• Monitor debit notes and ensure adherence to DOA and policy date controls.
• Assist in MVP implementations with OPD partners and ABHI alignment.

Skills

Excel data analysis

Audit and validation

MIS reporting

Tools

Excel

Job description

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.

Dimensions

Business Workforce Number: On Roll 6000+

Offroll/ Part time 4000+

Unit Workforce Number: On Roll 6000

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&Cs, 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 TPAs & OPD Partners Viz.
• DOA and policy date controls
  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;
• FWA and ABHI alignment and partner integration
  • 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 should be available
  • 12. Medicos to process