Team Member - Claim Control (Thane )

Basic Details: Fill the required information about business, unit, location, position, reports to position and date of updation of JD

Business Financial Service - HO

Unit Aditya Birla Health Insurance Company Ltd

Location Thane

Poornata Position Number of the job Reports to: Poornata Position Number

Poornata Position Title of the job (30 characters max) Reports to: Poornata Position Title

Function Services Operations

Reports to: Function Financial Service Operations

Department Ops - Claims

Reports to: Department Ops - Claims

Designation of the Employee Team Member – Claims Control

Designation of the Manager Head – Claims Control

Date of writing/updation of JD 20 th Apr 2026

• Job Purpose: Write the purpose for which the job exists (in 2-3 lines) (Max 1325 Characters) The role is responsible for establishing and maintaining a robust claims control framework that ensures regulatory compliance, quality assurance, and risk mitigation across the claims process. It drives governance through audits, fraud prevention, and leakage control, while leveraging MIS, analytics, and dashboards to provide actionable insights. The position also focuses on continuous process improvement and automation, enabling efficiency, transparency, and adherence to industry standards in claims management.
• Dimensions: Mention quantitative or qualitative parameters that are relevant for the job and provide a better understanding of the scope and scale of the job. Business Workforce Number (Max 254 Characters)

7000 Unit Workforce Number (Max 254 Characters)

7000 Function Workforce Number (Max 254 Characters)

700 Department Workforce Number (Max 254 Characters)

260 Other Quantitative and Important Parameters for the job: Budgets/ Volumes/No. of Products/Geography/ Markets/ Customers or any other parameter

• Job Context & Major Challenges: Write the specific aspects of the job that provide a challenge (internal and external) to the jobholder in the context of the Business/Unit/Function/Department/Section ((Max 3975 Characters)

About The Health Insurance Industry – While the current market sees more than 15 non-life players in the private space and 5 exclusive private players in the health insurance space trying to capture a sizable market share, the nationalized service provider (6) remains a strong competitor. In addition to this the business dynamics are such that the overall market on an annual basis which is to the tune of roughly 10,000 Crs sees close to 85 % of the business renewing with the existing service provider itself. This narrows down the opportunity of the fresh business actually being seriously fought in the market to approximately 1500 odd Crs. With the SME and the start-ups being the driving force of Indian economy, the opportunity to cater to these segments is immense and is increasing manifold year on year. The challenge here therefore remains as to how we capture a larger share of the opportunity by developing specific solutions to cater each segment of the business. Also by creating an inexpensive and standardized solution to increase the reach into the pockets of channel partners across the country to harness on their captive business and explore new opportunities with them. Market Opportunities – With the advent of medical advancements, lifestyle changes, change in Indian socio-economic scenario and Indian healthcare space, and the insurers are facing challenges to cater to the needs of this diverse clientele. Increasingly Indian customers have started considering health insurance partners as extensions of health advisers. In this scenario it becomes extremely important to understand their psyche and then provide tailored solutions with wellness benefits which would help them meet their end objectives and bring in profitable revenue source for the company.

About The Aditya Birla Health Insurance – Aditya Birla Health Insurance Co. Limited (ABHICL) was incorporated in 2015 as a 51:49 joint venture between Aditya Birla Capital Limited (ABCL) and MMI Strategic Investments (Pty) Ltd. ABHICL commenced its operations in October 2016. ABHICL has entered the competitive health insurance market with an aim to expand the category to wider customer segments, beyond the ones that health insurance companies traditionally have marketed to. As the 6th entrant in a category with well-established players, ABHICL is creating differentiation and equity for itself though the unique business proposition of “Health Insurance for All”, a one of a kind proposition in India at the moment. This is a philosophy that is being built through every single consumer touch point and into every single backend process of the company to ensure a customer’s experience of our proposition is continuous and seamless. ABHI’s unique offering to market includes proposition includes -

• A Comprehensive Incentivized Wellness Program that will attract the young and health conscious and will motivate, guide and reward them to stay healthy
• A Chronic Care Management Program to cater to the unmet needs of a growing Indian population of those suffering from chronic lifestyle conditions like Diabetes, Asthma, High Cholesterol and Hypertension from Day 1
• ABHICL serves as an enabler and influencer of health and healthcare choices that customers make, in addition to being a payer of healthcare expenses. Thus, ABHICL would act like a much needed catalyst to grow the prevalent health insurance landscape in India through product innovations and a wider choice of consumer relevant products.
• ABHICL’s vision has always been digital. The company has been successful in adopting paper-less approach right from identifying to on-boarding to delivering seamless experience of its customers & employees.

Challenges –

• To ensure to publish MIS, Regulatory Data submission, Analysis on periodic basis with effective controls built in and allied activities by overcoming system and infrastructure constraints.
• To identify trends, alert and suggest strategies towards risk/fraud mitigation strategies and policies within the framework of Compliance/ Group’s Policies.
• To identify and prevent regulatory breach of Claims TAT’s, and timely data submission by overcoming challenges related to systems and infrastructure, using manual methods where required.
• Key Result Areas: Write the key results expected from the job and the supporting actions for each of these key result areas (For a majority of jobs typically there could be 4- 7 key result areas)- Maximum 10 KRAs can be updated

Key Result Areas ( Max 1325 Characters) Supporting Actions (Max 1325 Characters) Claims Control Framework & Governance

• Implement end-to-end claim control frameworks, SOPs, checklists and monitoring mechanisms Regulatory & Compliance Adherence
• Ensure adherence to IRDAI regulations, TAT norms, policy wording and internal guidelines Claims Quality & Risk Reviews
• Conduct periodic claim quality audits, high-value claim reviews and exception analysis Fraud & Leakage Prevention
• Identify risk indicators, trends and root causes; recommend preventive and detective controls MIS, Analytics & Dashboarding
• Develop control MIS, dashboards and analytical reports using Excel, SQL/tools where applicable Process Improvement & Automation
• Identify control gaps and drive process simplification, automation and system enhancements
• Job Purpose of Direct Reports: Describe the job purpose of the direct report/s to the job (in 2-3 lines for each report) NA
• Relationships: Describe the nature and purpose of most important contacts or relationship (except superior/team members) with individuals, departments, organizations inside and outside of the organization, that job is required to interact with in order to deliver the job objectives

Relationship Type (Max 80 Characters) Frequency

Nature (Max 1325 Characters) Internal

External NA

• Organizational Relationships: Provide the structure for a level above and below the position for which this job description is written. Use position titles in the structured and indicate all the reports of the position.

SIGN-OFF: Provide the name of the Manager and the jobholder. Signature needed for the hard copy of the JD. Hard copy to be maintained in the organizational record. Job Holder

Reports to – Manager Name Signature (needed for the hard copy)