Team Member - Cashless Claims

Role Overview

This position sits within the claims function and is focused on coordinating with a service-provider partner to ensure Travel and OPD claims are settled on time. The role also requires regular medical and technical audits of claims cleared by the partner, along with maintaining accurate MIS and claims-related reporting.

Organizational Details

Business: Financial Service – HO

Unit: Aditya Birla Health Insurance Company Ltd

Location: Thane, Maharashtra

Function: Services Operations

Department: Claims

Position: Assistant/Deputy Manager - Claims

Manager Level: Manager / Sr. Manager

Date of JD update: 08.01.2024

Job Purpose

The role exists to support timely processing and settlement of Travel and OPD claims by working closely with the partner operations team. It also involves auditing approved claims for medical and technical accuracy and ensuring claims MIS and reporting are maintained properly.

Scope and Scale

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

Key Challenges

Maintaining claim quality while meeting the agreed turnaround time and SLA for audits and processing is a major part of the role.

Key Result Areas

Accurate and timely reporting

• Prepare and submit periodic as well as ad hoc claims reports within timelines.
• Use Excel shortcuts, formulas, or alternate tools and methods to speed up reporting.
• Carry out basic checks before sending out reports.

Audit observation closure

• Train partner claim processors on policy terms and conditions, time management, and delegation.
• Use strong coordination, quick judgment, initiative, soft skills, and Excel proficiency to close observations effectively.

Monthly, quarterly, and annual data submission

• Work in close coordination with internal and external stakeholders for data submissions.

Data and MIS management

• Coordinate with external data teams for reports such as LDR monitoring, daily intimation reports, monthly TAT MIS, and OPD FWA savings data.

Debit note monitoring

• Review debit notes for payments from TPAs and OPD partners.
• Ensure required validations are in place, including admission/discharge dates, policy dates, intimation dates, claimed and paid amounts, and sum insured remarks.

MVP implementation with OPD partners

• Work with partner leadership and technology teams on MVP rollouts and process enhancements.
• Support automated FWA triggers, ICD-10 data capture, home collection preference in health check-ups, agreed FWA investigation levels, and rule-engine alignment.
• Enable real-time dashboards, system access for claim approval, ABHI-format communication letters, automated reports and payment vouchers, query management, data digitization, API integrations, limit/sublimit controls, portal-level exhausted-wallet visibility, cashless end-to-end access, daily claim outstanding reports, and symptom-based slot booking.

Relationships

Internal: Ongoing coordination with the MIS team to collate data requirements and align with MIS templates for partner payment processing.

External: Interaction with service-provider partners as needed to support claim decisions, reconsideration requests, claims beyond partner authority, and future process or system enhancements.

Organizational Relationships

The JD notes that the structure should reflect the reporting line above and below the role, and that the job holder reports to the Manager. It also states that a hard copy of the JD must be signed by the manager and the job holder and retained in organizational records.

Additional Information

Poornata position title: Assistant/Deputy Manager - Claims

Poornata reporting title: Manager/ Sr. Manager

Function: Services Operations

Department: Claims

Designation of employee: Assistant/Deputy Manager

Designation of manager: Manager/ Sr. Manager

Direct reports: Not applicable

Job holder sign-off: Required on hard copy of the JD, with signature and name