Team Member - Claims Control

About the Role

This position is responsible for creating and maintaining a comprehensive claims control framework ensuring compliance with regulations, quality assurance, and risk management across the claims process. The role enforces governance through audits, fraud prevention, and leakage control. It also utilizes MIS, analytics, and dashboards to generate actionable insights. Continuous improvement and automation efforts focus on enhancing efficiency, transparency, and adherence to industry standards in claims handling.

Organizational Context

The role falls under Financial Service - HO, within Aditya Birla Health Insurance Company Ltd, located at Thane. Reporting to the Head of Claims Control, the employee is part of the Services Operations function and the Operations - Claims department.

About Aditya Birla Health Insurance

Incorporated in 2015 as a joint venture, Aditya Birla Health Insurance Co. Ltd operates with a vision of "Health Insurance for All," targeting diverse customer segments and offering innovative wellness and chronic care management programs. The company emphasizes digital processes to provide seamless customer experiences.

Industry and Market Challenges

• Highly competitive health insurance sector with established national and private players.
• Limited fresh business opportunities, with a majority of renewals retained by existing insurers.
• Opportunities to develop tailored, cost-effective solutions for growing SME and startup sectors.
• Increasing customer expectations with a shift towards health insurance providers acting as health advisors, requiring customized wellness benefits.

Job Challenges

• Publishing MIS and regulatory reports despite system limitations.
• Identifying and mitigating fraud and regulatory breaches through manual and automated controls.
• Ensuring timely data submission and compliance with claims turnaround time regulations.

Key Responsibilities

• Develop and enforce comprehensive claim control frameworks, SOPs, checklists, and monitoring tools.
• Ensure adherence to IRDAI regulations, turnaround times, policy terms, and company policies.
• Conduct periodic quality audits and detailed reviews of high-value claims.
• Detect and mitigate fraud through risk trend analysis and implementing effective controls.
• Prepare and maintain MIS reports, dashboards, and analytics using Excel, SQL, or other tools.
• Identify process gaps and lead initiatives to simplify, automate, and enhance systems.

Additional Details

Position updated on: 20 April 2026

Workforce scope: Business Unit - 7000 employees; Function - 700 employees; Department - 260 employees.