Assistant/Deputy Manager - Claims (Thane)

Overview

This role is integral to coordinating with service provider partners to ensure timely claim settlements for Travel and OPD claims. It involves conducting routine medical and technical audits on approved claims while maintaining accurate MIS and reports related to claims processing.

Organizational Context

The position is within Aditya Birla Health Insurance Company Ltd under the Financial Service – Head Office, located in Thane. The employee reports to the Manager/Sr. Manager of the Services Operations function in the Claims department.

Scope and Scale

The business comprises over 6000 full-time employees and 4000+ part-time/offroll staff. The Services Operations function includes 800 full-time and 279 part-time workers, with the Claims department staffed by 69 full-timers and 66 part-timers.

Role Challenges

A major challenge in this role is ensuring high-quality claim processes and audits while adhering to turnaround times as per the service level agreements.

Key Responsibilities

• Provide accurate and prompt submission of both regular and ad-hoc claim-related reports.
• Create and implement Excel shortcuts, formulas, and alternative tools to expedite reporting.
• Perform preliminary sanity checks before report submission.
• Ensure closure of audit observations through partner training focusing on policy terms, time management, and delegation.
• Maintain strong collaboration with other departments, apply sharp thinking, proactive problem solving, and utilize strong communication and Excel skills.
• Submit monthly, quarterly, and annual datasets in coordination with internal and external stakeholders.
• Engage with external data teams to manage reports such as LDR, daily intimation, monthly TAT MIS, and OPD FWA savings.
• Monitor debit notes related to payments from TPAs and OPD partners ensuring compliance with documentation and date fields like policy start/end dates and admission/discharge dates.
• Lead MVP implementations with OPD partners, including automation of FWA triggers, ICD-10 coding integration, client dashboards, system access for approvals, and system-based limits and validations for utilization and claim approvals.
• Manage query resolution with deficiency options and ensure data digitization with automated reporting and API integrations.

Key Relationships

• Internal: Collaborate regularly with the MIS team for data coordination and payment processing templates.
• External: Liaise as needed with service provider partners for claim decisions, reconsiderations, and system enhancements.

Additional Information

Job holder reports to a Manager. The job description was last updated on 08.01.2024. There are no direct reports to this position. The organizational hierarchy includes Manager/Sr. Manager above, with Assistant/Deputy Manager positioned to execute responsibilities.