- Experience
- Any
- Salary
- —
- Openings
- 1
- Posted
- 3 weeks ago
- Work mode
- In office
- Education
- Any graduate
- Eligibility
- <ul><li>Open to candidates who can apply.</li></ul>
- Resume
- Required to apply
Where you'll work
Job description
Job Purpose
This role is responsible for coordinating with service provider partners to ensure the timely settlement of Travel and OPD claims. The candidate will conduct regular medical and technical audits of claims approved for settlement by the partner and maintain relevant MIS/Reports.
Basic Details
Business: Financial Service – HO
Unit: Aditya Birla Health Insurance Company Ltd
Location: Thane
Position Number: [To be filled]
Reports to Position Title: Assistant/Deputy Manager - Claims
Function: Services Operations
Department: Claims
Designation of the Employee: Assistant/Deputy Manager
Designation of the Manager: Manager/ Sr. Manager
Date of JD Updation: 08.01.2024
Dimensions
Business Workforce Number: On Roll – 6000+, Off Roll/Part time – 4000+
Unit Workforce Number: On Roll – 6000, Off Roll/Part time – 4000+
Function Workforce Number: On Roll – 800, Off Roll/ Part time - 279
Department Workforce Number: On Roll – 69, Off Roll/ Part time - 66
Job Context & Major Challenges
Ensuring quality in the claim process and audit, while managing Turnaround Time (TAT) as per agreed Service Level Agreements (SLAs) presents a significant challenge.
Key Result Areas
- Accurate and timely submission of periodic and ad-hoc reports related to Claims: Develop and implement shortcuts, formulae on Excel, or use alternative tools/methods for timely submission. Conduct cursory/sanity checks before submission.
- Closure of audit observations: Provide training to partner claim processors on policy terms and conditions, time management, and delegation. Utilize strong coordination skills, proactive approach, soft skills, and Excel proficiency.
- Monthly / Quarterly / Annual Data submission: Work closely with related internal and external stakeholders.
- Working on DATA / MIS: Collaborate with data teams of external stakeholders for reports such as LDR reports, 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 fields like DOA, future admission dates, discharge dates relative to admission, policy period validity, and paid amount versus claimed amount.
- MVP implementations with OPD partners: Coordinate with Partner leadership and tech teams for MVP implementations, including FWA triggers, automated ICD 10 coded data, utilization drives for health check-ups, FWA investigations, alignment of reimbursement claim adjudication rule engines with ABHI processes, real-time client dashboards, system access for claim approval, communication letters, reports, and payment vouchers in ABHI format, mandatory fields in debit notes, query management, medico processing of OPD claims, data digitization, API integrations, limit and sublimit definitions in partner systems, portal validation for exhausted wallet amounts/sub-limits, cashless portal access, claim outstanding reports, and symptom linking prior to slot booking.
Relationships
Internal: Coordinate and collate data requirements with the MIS Team. Liaise with the MIS template for processing partner payments.
External: Engage with External Partners (Service providers) as needed to decide on claims, reconsiderations, claims beyond partner authority, and developments/enhancements.
Organizational Relationships
Reports to: Manager/Sr. Manager
Direct Reports: None (NA)