Assistant Manager - Retail Claims

A. Position Overview

Position Title - Assistant Manager

Department - Retail Claims

Level/ Band - 301

B. Role Summary

• Conduct comprehensive quality checks on all adjudicated death claims with a strong focus on risk identification and mitigation.
• Validate the accuracy of claim benefits in line with product features, policy terms, and internal guidelines.
• Analyze emerging trends and collaborate with internal stakeholders to strengthen the claim quality control framework.
• Ensure adherence to all internal, regulatory, and audit requirements while delivering outcomes within defined timelines.
• Identify process gaps, recommend improvements, and drive enhancement projects aligned with business objectives.
• Manage endtoend processing of all death claims, ensuring accuracy, transparency, and timely resolution.
• Handle all customer communications with clarity, empathy, and professionalism.
• Maintain data integrity and manage all reports related to claims performance and governance.
• Address claimsrelated complaints and assist walkin customers with prompt and effective resolutions.
• Apply strong claim assessment principles, including verification of documentation, assessment of medical and financial underwriting aspects, and evaluation of potential fraud indicators to ensure fair and just claim decisions.

C. Organizational Relationships

Reports to - Sr Manager - Claims

Supervises - NA

D. Job Dimensions

Geographic Area Covered - PAN -India

Stakeholders -

Internal - Finance,POS, underwriting team, Branch ops, RCU, IT, Customer Service, Legal & Compliance

External - External legal consultant, legal counsel, investigators, Claimants, Customers and Claim consultants

E. Key Result Areas

Organization Process

Key Contribution -

Claims QC

• Good knowledge of insurance & products & claim operations
• Ensure 100% quality checking of death claims to validate adherence to claim processes
• Impart training to assessment team based highlighting common lapses noted during daily QC.
• Ensure compliance with all internal & regulatory requirements and delivery in lines with the same.
• Regular update of QC checklist to ensure addition of new checkpoints and deletion of redundant checkpoints

Implement control measures for QC error reduction and ensuring correct claim payment

• Take measures necessary to reduce repetitive errors and improve overall Quality score
• Prepare control reports for proactive identification of process gaps
• Identify areas of improvement and liaise with internal stakeholders to take up automation projects for speedy resolution of process gaps and QC errors
• Conduct periodic internal audits for proactive identification of risk areas and process lapses

Manage all regulatory, compliance & audit requirements for claims team

• Manage process walkthrough and assist in query response
• Manage and prepare data for compliance, regulator and audit requirements for ensuring timely closure
• Conduct pre-audit reviews

F. Competencies

• Customer & Consumer Engagement and experience in a hybrid world -3
• Business Acumen and domain knowledge - 4
• Networking and collaboration- 3
• Change management- 3
• Developing managing & working with hybrid teams- 3
• Technology, Digital and analytics-3

G Skills Required

Technical -

• Claims Processing.
• Sound knowledge of regulatory reporting, registrations.
• Regulatory guidelines.
• Presentation skills.
• Communication skill

Behavioral -

Essential

• Interpersonal skills
• Communication skills
• Creative thinking skills
• Teamwork Skills
• Decision making skills

Desired

• Supervising/Leadership skills
• Influencing skills
• Relationship Building skills

H Incumbent Characteristics

Qualification

Essential - Graduate

Desired - MBBS, BHMS, BAMS

Experience - 2-3 Years