Manager - Operations Claims

Role overview

This position supports the timely processing and settlement of travel and OPD claims by coordinating closely with the service provider partner team. The role also includes carrying out regular medical and technical audits on claims approved by the partner and maintaining accurate claim-related MIS and reports.

Job details

Business: Financial Service – HO

Unit: Aditya Birla Health Insurance Company Ltd

Location: Thane, Maharashtra, India

Function: Services Operations

Department: Claims

Designation: Assistant/Deputy Manager

Reporting level: Manager / Sr. Manager

JD updated on: 08.01.2024

Role purpose

The objective of this job is to ensure the claims process runs with strong quality control, accurate audits, and adherence to the agreed turnaround time. The role demands effective coordination with external partners, prompt reporting, and disciplined monitoring of claims-related data.

Key responsibilities

• Prepare and submit periodic as well as ad hoc claims reports accurately and on time.
• Create efficient Excel shortcuts, formulas, or alternative methods to speed up report preparation and delivery.
• Carry out sanity checks and basic validation before sharing reports.
• Address and close audit findings by working with the partner claim processing team.
• Train partner claim processors on policy terms and conditions, time management, and delegation practices.
• Work closely with internal and external stakeholders for monthly, quarterly, and annual data submissions.
• Handle claims MIS and data coordination with external data teams.
• Track and maintain reports such as LDR, daily intimation reports, monthly TAT MIS, and OPD FWA savings data.
• Monitor debit notes and review payment-related checkpoints for TPA and OPD partner transactions.
• Check claim records for issues such as missing DOA, invalid future admission dates, discharge before admission, missing policy dates, policy date mismatches, admission outside policy period, payment anomalies, and other validation points.
• Support MVP implementations with OPD partners by coordinating with partner leadership and technology teams.
• Help enable automated FWA triggers, ICD-10 coded data capture, home collection usage in health check-ups, and agreed FWA investigation levels.
• Work toward alignment of reimbursement adjudication rules, real-time client dashboards, ABHI access for claim approvals, communication templates, payment vouchers, and other system/process enhancements.
• Ensure reports capture all audit-relevant fields and that debit notes contain mandatory data points.
• Support query management, including deficiency handling options.
• Coordinate on digitization, automated reporting, API integrations, limit and sub-limit controls, wallet utilization checks, cashless portal access, outstanding claim MIS, and symptom linking before consultation slot booking.

Work context and challenges

The main challenge in this role is maintaining claim quality and audit accuracy while meeting agreed SLA-based turnaround times. The job requires strong coordination across teams and constant attention to data integrity and process compliance.

Stakeholder interactions

• Internal: Ongoing coordination with the MIS team to collect data requirements and support partner payment processing through the agreed template.
• External: Regular interaction with service provider partners to support claim decisions, reconsideration cases, exceptions beyond partner authority, and process or product enhancements.

Reporting structure and documentation

The JD notes that the position reporting structure includes a manager-level contact and requires hard-copy sign-off and record maintenance. It also states that direct reports are not applicable for this role.

Additional notes

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

The document also mentions a sign-off section for the job holder and the reporting manager, with signature required on the physical copy of the JD. No direct reports are specified.