Team Lead - Claims

Role overview

This position is responsible for overseeing claims payments for both indemnity and fixed benefit claims, ensuring they are completed within the defined turnaround time and in line with IRDA guidelines.

Business and team context

The role sits within Health Insurance under Aditya Birla Health Insurance Company Ltd, in the Services Operations function and Ops - Claims department. It is a team lead role reporting to the Head of Reimbursement/Cashless Claims, with an Associate VP as the manager level mentioned in the source JD.

Scope and performance expectations

The job covers in-house and TPA-handled claims, including pre-authorisation, reimbursement, denial decisions, quality checks, audit activities, and process improvement. The role is expected to help maintain service standards, claim accuracy, control turnaround times, and support profitability through better claims management.

• In-house pre-authorisation decisions must be handled within 2 hours for approval, denial, response, or query.
• Reimbursement claims are expected to be processed within 5 working days.
• Overall claims processing turnaround time is 7 days.
• Grievance resolution target is 15 working days.
• Claims service benchmarks must be monitored and maintained for cashless, reimbursement, and combined metrics.
• Claim approvals and denials must follow the defined authority matrix.
• TPA pre-authorisation approvals are expected within 30 minutes.
• TPA pre-authorisation and reimbursement denials are part of the role scope.
• Quality checks are required for claims processed in the in-house ABHI system.
• Paid claims handled by TPAs must be audited periodically.
• Support is needed for gathering requirements and assisting in claims system development.

Key responsibilities

The role involves managing end-to-end claims operations, improving processes, guiding the team, and ensuring compliant claim settlements for retail and group products.

• Design, monitor, and improve claims workflows, SOPs, and operating protocols for both in-house and partner TPA claims.
• Ensure the team is brought up to speed quickly through functional and product training.
• Support system development, user acceptance testing, and claims-related product changes for indemnity and fixed benefit products.
• Manage team expectations, turnaround commitments, and specialized business handling requirements.
• Ensure claims decisions follow approved guidelines, authority limits, and compliance requirements.
• Review claims portfolio performance and work to sustain strong service delivery, customer satisfaction, and client retention.
• Help reduce loss ratio and monitor portfolio profitability.
• Track claims transactions, authority compliance, and turnaround times, and resolve escalations in a timely manner.
• Measure the quality and timeliness of claims decisions for both in-house and TPA-processed claims.
• Review outstanding claims and recommend delegation of authority to claims officers where appropriate.
• Conduct audits, support training, and benchmark claims guidelines against market practices.
• Analyse trends, recommend process changes, and complete cost-benefit assessments.

Working context and challenges

The health insurance market is highly competitive, with established private and public players competing for renewals and new business. A major challenge is to create efficient, standardised, and affordable solutions that can scale across different customer segments, geographies, and partner channels.

The business also expects the role to respond to changing customer expectations, medical advancements, and the increasing need for health insurers to act as trusted health advisers rather than only claim payers.

Additional challenges include maintaining consistency across in-house and TPA claims, managing system enhancements, handling UAT, ensuring claims compliance, and aligning team performance with strict TAT and service expectations.

Relationships

This position works closely with a wide range of internal and external stakeholders to keep claims movement smooth and compliant.

• Internal teams: New Business and Policy Administration, Legal/Compliance, Sales, IT, Underwriting, Internal Audit, Provider Management, Product Team, and Actuary Team.
• External stakeholders: Policyholders, vendors, external auditors, brokers, and partner TPAs.
• Typical interactions include policy and endorsement clarifications, dispute handling, vendor agreement and SOP coordination, system support, audit support, MIS updates, claims payment status sharing, and query resolution.

Direct report

The source document identifies Sr. Executive – Claims as the direct report. This role is expected to settle valid claims and benefits within authority limits and within the IRDA-mandated timeline.

Additional information from the JD

The source JD lists the business as Health Insurance, the unit as Aditya Birla Health Insurance Company Ltd, and the location as MBC, Thane. It also records the job title as TM-Mrg-Claims-3-Thane and notes that the JD was updated on 20 July 2021.

The document contains a structured template with fields for workforce numbers, position numbers, sign-off names, and signature records. Those fields were present as template placeholders and were not filled in the source.

The JD also references organizational records, hard-copy maintenance, and sign-off by both the manager and the job holder.