TM-Ops Claims (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)

Assistant/Deputy Manager - Claims

Reports to: Poornata Position Title

Manager/ Sr. Manager

Function

Services Operations

Reports to: Function

Services Operations

Department

Claims

Reports to: Department

Team Lead – Claims

Designation of the Employee

Assistant/Deputy Manager/ Manager

Designation of the Manager

Manager/ Sr. Manager/ DCM/ CM

Date of writing/updation of JD

08.01.2024

• Job Purpose: Write the purpose for which the job exists (in 2-3 lines) (Max 1325 Characters)
  
  

The Medical Claims Processor – PreAuth is responsible for the accurate and timely assessment, processing, and authorization of cashless hospitalization requests in accordance with policy terms, medical guidelines, and company procedures. The role ensures adherence to service level agreements (SLAs), quality standards, and regulatory requirements while delivering an excellent customer experience.

• 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)

On Roll – 6000+

Offroll/ Part time – 4000+

Unit Workforce Number

(Max 254 Characters)

On Roll – 6000

Offroll/ Part time – 4000+

Function Workforce Number

(Max 254 Characters)

On Roll – 800

Offroll/ Part time - 279

Department Workforce Number

(Max 254 Characters)

On Roll – 69

Offroll/ Part time - 66

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)
  
  

The Medical Claims Processor – PreAuth operates in a high-volume, time-sensitive environment where prompt and accurate claim decisions directly impact customer experience and healthcare service delivery. The role requires evaluation of pre-authorization requests received from hospitals by reviewing policy coverage, medical documentation, treatment necessity, exclusions, waiting periods, and claim eligibility while adhering to defined turnaround times (TATs) and quality standards.

The key challenge is balancing speed with accuracy, as authorization decisions must be made within stringent SLA timelines without compromising on quality, compliance, or risk management. The incumbent is required to coordinate with hospitals, medical teams, customers, and internal stakeholders to obtain complete and

The role also involves handling reimbursement/Pre Auth/ Retail/Group medical cases, incomplete documentation, treatment justification reviews, policy interpretation issues, and escalations from hospitals or customers. Ensuring compliance with organizational policies, regulatory requirements, fraud control measures, and audit standards while maintaining productivity and service quality is a critical aspect of the position.

Major Challenges

• Managing high volumes of all types of claims (retail/group) requests within defined TATs.
• Ensuring accurate claim decisions while minimizing operational and financial risk.
• Reviewing all levels of medical cases and treatment protocols.
• Handling incomplete or inadequate documentation from hospitals.
• Managing customer and hospital expectations during urgent hospitalization cases.
• Identifying potential fraud, abuse, and policy misuse.
• Maintaining quality scores, audit compliance, and productivity targets simultaneously.
• Coordinating effectively with medical experts, hospitals, TPAs, and internal functions for timely claim resolution.
• Keeping abreast of policy updates, medical advancements, and regulatory changes impacting claim adjudication.
• 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)

Accurate and timely submission of periodic and ad-hoc reports related to Claims

• Develop, Implement shortcuts, formulae on excel, using alternative tools/methods for timely submission
• Do cursory/sanity checks before submission
  
  

Closure of audit observations

• Trainings to the partner claim processors regarding policy T&C's, Time management, Delegation
• Strong coordination skills with other departments, sharp and on the spot thinking, proactive approach, soft skills, excel skills etc.
  
  

Monthly / Quarterly / Annual Data submission

• Work closely with related stake holders (internal and external)
  
  

Working on DATA / MIS

• Work closely with data teams of external stake holder for reports viz;
• LDR report & monitoring
• Daily intimation reports
• Monthly MIS check - For TAT
• OPD FWA Savings data
  
  

DN monitoring for check pts

Debit note supervision for all the payments from TPA's & OPD Partners Viz.

DOA should not be empty

Future date of admission should not be mentioned.

Date of discharge < Date of Admission

Policy start date should not be blank

Policy end date should not be blank

Policy end date < Policy start date

Policy start date > Date of Intimation

Date of Admission should be falling within Policy period

Paid amt>Claimed Amt

Paid date

Paid amt>SI Remarks

MVP implementations with OPD partners

• Coordinating with Partner leadership teams /tech teams for MVP implementations viz;
• FWA triggers implemented in the system (automated)
• Automated ICD 10 coded data is needed.
• In health check-ups utilization should be driven towards home collection instead of hospitals.
• FWA investigations are to be conducted in the agreed percentage of claims.(Partner end)
• The reimbursement claim adjudication rule engine (automated) should be aligned with the ABHI process.
• Real time client Dashboard for client reviews.
• ABHI to be given system access for claim approval
• Communication letters in ABHI format
• Reports and Payment voucher in ABHI format (automated)
• All fields required in reports to be captured in system for auditing (Debit note to have mandate fields)
• Query management – under deficiency option should be available
• Medicos to process OPD claims
• Data digitization and automated reports to be available
• API integrations
• Limits and Sublimits to be defined in the partner system to ensure no over utilization
• Portal per insured/family should reflect exhausted wallet amount/sub limits and there should be validation in the system to limit utilization up to opted SI
• Cashless - Portal access end to end
• Claim Outstanding report (Daily MIS) to be shared
• Symptom linking prior to slot booking for consultations
• 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 (individual contributor role)

• 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

Internal (MIS Team)

Ongoing

To coordinate and collate the data requirement. Coordinate with MIS template for processing payments of the partner

External

External Partners (Service providers)

As and when required

To decide on claims, reconsideration claims and claims beyond the authority of the Partner processing team, developments/ enhancements.

• 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)