DM-Ops-Claims

Role overview

This position is responsible for managing claim settlements across the assigned verticals. The incumbent will either approve and process claims or reject them according to the applicable guidelines, while ensuring closure within the defined turnaround time.

Business context and challenges

The role operates in a highly competitive insurance environment, with more than 15 private non-life insurers and 5 private health insurance specialists competing for market share. Nationalized service providers also remain strong competitors. The market is sizeable, with annual business of around 10,000 crores and nearly 85% renewal business.

The organization’s offerings include a wellness program designed to reward and encourage healthy behaviour, along with a chronic care management program aimed at conditions such as diabetes, asthma, high cholesterol, and hypertension from day one. The company also positions itself as a health and healthcare enabler, not just a payer, and aims to strengthen the health insurance ecosystem through product innovation and broader consumer-focused choices.

The company has a digital-first vision and has historically adopted a paperless approach across customer and employee journeys, from identification and onboarding to service delivery.

Key responsibilities

• Design, track, and continuously improve claim processes, SOPs, and protocols for both in-house claims handling and claims managed through partner TPAs.
• Ensure team members are brought up to speed quickly and supported through regular functional and product training.
• Support system development and user acceptance testing for claims related to indemnity and fixed benefit products across retail and group business.
• Manage expectations around claims service levels, turnaround times, and specialised business handling.
• Ensure claims decisions follow approved guidelines, remain consistent, and stay within delegated authority limits for both internal and TPA claims.
• Review portfolio performance periodically and maintain reliable service delivery to support client retention and satisfaction.
• Work to reduce loss ratio and monitor the profitability of the portfolio.
• Handle cashless indemnity claims processing and monitoring, including escalation resolution and performance tracking.
• Track team performance metrics, claims quality, cashless turnaround time, and retrospective quality outcomes.
• Analyse claims trends across channels and share insights and recommendations with claims and underwriting teams using calling intelligence.
• Oversee team management, fraud and abuse controls, claim ratio monitoring, and process enhancement initiatives.
• Review outstanding claims and support audits, training, and empowerment recommendations for claims officers.
• Assess claims guidelines against competitors, analyse business trends, and recommend improvements backed by cost-benefit analysis.

Requirements

• Strong understanding of insurance law, health products, and medical terminology.
• Ability to evaluate claims within policy guidelines, approval limits, and service-level targets.
• Experience in monitoring claim quality, turnaround time, and team performance.
• Capability to analyse claims patterns, identify fraud or abuse, and support process improvements.
• Comfort working on system development and testing activities related to claims operations.
• Ability to conduct training, review portfolios, and contribute to operational decision-making.

Additional information

No salary, stipend, duration, start date, or application deadline was specified in the source.