Assistant/Deputy Manager - Claims
Maharashtra, India · Part Time
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- Experience
- Any
- Salary
- —
- Openings
- 1
- Posted
- 3 weeks ago
- Work mode
- In office
- Education
- Any graduate
- Eligibility
- <ul><li>Candidates with experience in claims processing and management are preferred.</li><li>Individuals with strong analytical and coordination skills are encouraged to apply.</li><li>Open to candidates who can effectively manage relationships with external service providers.</li></ul>
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Where you'll work
Job description
Job Summary
This role is responsible for overseeing the timely settlement of Travel and OPD claims by coordinating with service provider partners. The position involves conducting regular medical and technical audits of claims approved by the partner and maintaining relevant MIS and reports.
Basic Details
Business: Financial Service – HO
Unit: Aditya Birla Health Insurance Company Ltd
Location: Thane
Position Title: Assistant/Deputy Manager - Claims
Reports To: Manager/ Sr. Manager
Function: Services Operations
Department: Claims
Designation: Assistant/Deputy Manager
Date of JD Updation: 08.01.2024
Job Purpose
To ensure the timely settlement of Travel and OPD claims through effective coordination with service provider partners. This includes performing medical and technical audits on approved claims and managing associated MIS and reports.
Dimensions
Business Workforce: On Roll – 6000+, Offroll/ Part time – 4000+
Unit Workforce: On Roll – 6000, Offroll/ Part time – 4000+
Function Workforce: On Roll – 800, Offroll/ Part time - 279
Department Workforce: On Roll – 69, Offroll/ Part time - 66
Job Context & Major Challenges
The primary challenge is to maintain the quality of the claims process and audits while adhering to agreed Service Level Agreements (SLAs) for Turnaround Time (TAT). This requires strong coordination, proactive thinking, and effective problem-solving skills.
Key Result Areas
- Accurate and timely submission of periodic and ad-hoc reports related to Claims: Develop and implement shortcuts or formulas in Excel, or utilize alternative tools for efficient report submission. Conduct preliminary checks before submission.
- Closure of audit observations: Provide training to partner claim processors on policy terms and conditions, time management, and delegation. Foster strong coordination with other departments, encourage sharp and on-the-spot thinking, and promote a proactive approach with strong soft skills and Excel proficiency.
- Monthly / Quarterly / Annual Data submission: Collaborate closely with relevant internal and external stakeholders.
- Working on DATA / MIS: Work closely with external stakeholder data teams for reports such as LDR reports and monitoring, daily intimation reports, monthly MIS checks for TAT, and OPD FWA Savings data.
- DN monitoring for check points: Supervise debit notes for all payments from TPAs & OPD Partners, ensuring accuracy in dates (admission, discharge, policy period), amounts, and policy details. Verify that DOA is not empty, future admission dates are not mentioned, and policy start/end dates are valid and within the policy period. Ensure paid amount does not exceed claimed amount and paid date is valid.
- MVP implementations with OPD partners: Coordinate with partner leadership and tech teams for MVP implementations, including FWA triggers, automated ICD 10 coded data, promoting home collection for health check-ups, conducting FWA investigations at the agreed percentage, aligning reimbursement claim adjudication with ABHI processes, developing real-time client dashboards, providing ABHI system access for claim approval, using ABHI formats for communication letters, reports, and payment vouchers, capturing all required fields for auditing, implementing query management under deficiency options, having medicos process OPD claims, ensuring data digitization and automated reports, implementing API integrations, defining limits and sublimits in partner systems to prevent overutilization, ensuring portals reflect exhausted wallet amounts/sublimits with system validations, providing end-to-end cashless portal access, sharing daily Claim Outstanding reports, and linking symptoms prior to slot booking for consultations.
Relationships
- Internal (MIS Team): Ongoing interaction to coordinate and collate data requirements and process partner payments using MIS templates.
- External Partners (Service providers): As and when required, to make decisions on claims, reconsiderations, claims exceeding partner authority, and for developments/enhancements.
Organizational Relationships
Reports to: Manager/ Sr. Manager
Direct Reports: None (NA)