Vertical Head Health Claims Reimbursement

Bajaj General Insurance; Pune District; Presencial; INR 1 200 000 - 1 800 000; Tempo integral

Resumo da oferta

Bajaj General Insurance Limited in Pune district seeks an experienced leader to manage end-to-end health claim processing, drive team performance, and ensure compliance with IRDAI and internal controls. The role includes governance, analytics, and fraud risk management.

The ideal candidate will have 7–12 years in health claims/reimbursement in GI/health/TPA spaces, with 2–3 years of managerial experience, and strong MS Office and claims systems proficiency.

Qualificações

• Graduate in any discipline.
• Preferred qualifications: BAMS, BHMS, MBBS.
• 7-12 years of experience in Health Claims/Reimbursement Operations within General Insurance, Health Insurance, or TPA organizations.
• Minimum 2-3 years of team-handling experience in a managerial capacity.

Responsabilidades

• Manage end-to-end reimbursement claim processing and settlement activities.
• Lead, mentor, and develop a team of claim assessors and executives.
• Ensure adherence to IRDAI regulations, internal controls, and audit requirements.
• Identify claim leakage trends and coordinate with investigation teams for fraudulent claims.
• Collaborate with hospitals, TPAs, service providers, underwriting, legal, and customer service teams.
• Analyze claim trends, repudiation ratios, and prepare MIS, dashboards and reports for senior leadership.
• Drive automation and process enhancement initiatives; monitor KPIs like settlements, accuracy, and CSAT.

Conhecimentos

Claims management

Leadership

Regulatory compliance

Analytical thinking

Stakeholder management

Communication skills

Process improvement

Formação académica

Graduate in any discipline

BAMS/BHMS/MBBS preferred

Ferramentas

MS Office

Claims management systems

Descrição da oferta de emprego

Key Responsibilities

Claims Operations Management

• Manage end-to-end reimbursement claim processing and settlement activities.
• Ensure claims are adjudicated in line with policy terms, medical underwriting guidelines, and company procedures.
• Monitor claim processing TATs and drive timely closure of cases.
• Review high-value, complex, and exception claims before settlement.

Team Leadership

• Lead, mentor, and develop a team of claim assessors and executives.
• Drive productivity, quality, and compliance within the team.
• Conduct regular performance reviews and capability-building initiatives.
• Ensure optimum workforce planning and resource utilization.

Quality & Compliance

• Ensure adherence to IRDAI regulations, internal controls, and audit requirements.
• Monitor claim quality scores and implement corrective actions.
• Prepare teams for internal, statutory, and regulatory audits.
• Maintain process documentation and ensure SOP compliance.

Fraud Risk Management

• Identify claim leakage trends and suspicious claim patterns.
• Coordinate with investigation teams for fraudulent or suspicious claims.
• Recommend process improvements to minimize fraud and operational risks.

Stakeholder Management

• Collaborate with hospitals, TPAs, service providers, underwriting, legal, and customer service teams.
• Resolve escalated customer grievances and complex claim-related issues.
• Build strong relationships with internal and external stakeholders.

Process Improvement & Analytics

• Analyze claim trends, repudiation ratios, and operational performance metrics.
• Drive automation and process enhancement initiatives.
• Prepare MIS, dashboards, and management reports for senior leadership.
• Recommend strategies for cost optimization and improved customer experience.

Eligibility Criteria

• Graduate in any discipline.
• Preferred qualifications: BAMS, BHMS, MBBS,
• 7-12 years of experience in Health Claims/Reimbursement Operations within General Insurance, Health Insurance, or TPA organizations.
• Minimum 2-3 years of team-handling experience in a managerial capacity.

Required Competencies

• Strong knowledge of health insurance claims and reimbursement processes.
• Sound understanding of medical terminology, treatment protocols, and hospital billing.
• Leadership and people management skills.
• Analytical and problem-solving ability.
• Decision-making and risk assessment capability.
• Stakeholder and customer management skills.
• Excellent communication and presentation skills.
• Proficiency in claims management systems and MS Office.

Key Performance Indicators (KPIs)

• Claims Settlement TAT
• Claims Accuracy Rate
• Quality Audit Score
• Team Productivity
• Customer Satisfaction Score (CSAT)
• Grievance Resolution Efficiency
• Fraud Detection & Prevention Effectiveness
• Regulatory & Audit Compliance
• Cost and Claim Leakage Control