Manager - Health Claims

A Position Overview

Position Title - Manager

Department - Health Claims

Role Summary:

• Responsible for Health claim processing (including End to End processing of claims) with Speedy decisions of all Health claims with strong eye on risk.
• Monitoring the TAT for the portfolio along with ensuring no regulatory TAT breach
• Expertise in reviewing claim documents, medical opinions and understanding policy terms and conditions
• Compliance to all Regulatory requirements and delivery in lines with the same
• Responsible for quality claim decisions within the agreed product guidelines and SLAs
• Understanding trends and liaison with internal stakeholders for exhaustive assessment of documents & facts of claim.
• Updating information in the claims system
• Responsible for all customer communication related to Health claims.
• Responsible for data management for all reports.
• Responsible for claims related complaints and walk in customers.
• Identify areas of improvement and take projects and delivery as per business objective
• Noting the trends of red flags, suspicious claims and reporting to management
• Providing regular feedback to underwriters on voided claims
• Risk assessment and triggering verification of suspicious claims
• Should be able to coordinate with FIU team, sales team, product team, legal team, complaints team, vendors etc for claims processing, escalations & litigation cases etc.
• Team management tracking team productivity, targets and ensuring regulatory TATs are not breached.

B Organizational Relationships

Reports to - AVP

C Job Dimensions

Geographic Area Covered - Pan India

Stakeholders -

Internal

FIU team, sales team, product team, legal team, complaints team

External

Customer/ Policyholder, Vendor

D Key Result Areas

Organization Process

Key Contribution

To ensure quality & accuracy of Health Claim processes

• Good knowledge on insurance & products & ability to take claim decisions as per policy terms and conditions
• Ensure 100% quality completion of Claim decision
• Ensure all cases are received by the department as per the specified inter & intra department SLAs.
• Presenting case summary and representing to reinsurers, communicating with distribution stakeholders
• Ensure adherence to defined claims TAT & decision accuracy
• Mentor, guide & train new team members
• Ensure quality & accuracy of Claims process
• Sharing feedback and conducting meetings with the relevant stakeholders time to time
• Evaluate emerging trends, competition practices and propose recommendations to senior management
• Managing the entire team and responsible for End to end TATs of Health claims as per regulatory guidelines

E Skills Required

Technical

• Medical background- Education minimum MBBS/ BAMS /BHMS
• Experience insurance experience, life + Health UW/claims
• Effective presentation and interpersonal skills.
• Good system skills in Excel/Word.
• Multitasking

Behavioral

Essential -

• Analytical & Excel Skills
• Communication skills
• Teamwork Skills
• Relationship Building skills
• Decision making skills

Desired -

• Influencing skills
• Supervising/Leadership skills

F Incumbent Characteristics

Essential

Qualification - Doctor

Experience - 8 - 10 years of experience in Health claim processing