Vertical Head Health Claims Reimbursement

Key Responsibilities

Claims Operations Management

• Manage end-to-end reimbursement claim processing and settlement activities.
• Ensure claims are adjudicated in line with policy terms, medical underwriting guidelines, and company procedures.
• Monitor claim processing TATs and drive timely closure of cases.
• Review high-value, complex, and exception claims before settlement.

Team Leadership

• Lead, mentor, and develop a team of claim assessors and executives.
• Drive productivity, quality, and compliance within the team.
• Conduct regular performance reviews and capability-building initiatives.
• Ensure optimum workforce planning and resource utilization.

Quality & Compliance

• Ensure adherence to IRDAI regulations, internal controls, and audit requirements.
• Monitor claim quality scores and implement corrective actions.
• Prepare teams for internal, statutory, and regulatory audits.
• Maintain process documentation and ensure SOP compliance.

Fraud Risk Management

• Identify claim leakage trends and suspicious claim patterns.
• Coordinate with investigation teams for fraudulent or suspicious claims.
• Recommend process improvements to minimize fraud and operational risks.

Stakeholder Management

• Collaborate with hospitals, TPAs, service providers, underwriting, legal, and customer service teams.
• Resolve escalated customer grievances and complex claim-related issues.
• Build strong relationships with internal and external stakeholders.

Process Improvement & Analytics

• Analyze claim trends, repudiation ratios, and operational performance metrics.
• Drive automation and process enhancement initiatives.
• Prepare MIS, dashboards, and management reports for senior leadership.
• Recommend strategies for cost optimization and improved customer experience.

Eligibility Criteria

• Graduate in any discipline.
• Preferred qualifications: BAMS, BHMS, MBBS,
• 7-12 years of experience in Health Claims/Reimbursement Operations within General Insurance, Health Insurance, or TPA organizations.
• Minimum 2-3 years of team-handling experience in a managerial capacity.

Required Competencies

• Strong knowledge of health insurance claims and reimbursement processes.
• Sound understanding of medical terminology, treatment protocols, and hospital billing.
• Leadership and people management skills.
• Analytical and problem-solving ability.
• Decision-making and risk assessment capability.
• Stakeholder and customer management skills.
• Excellent communication and presentation skills.
• Proficiency in claims management systems and MS Office.

Key Performance Indicators (KPIs)

• Claims Settlement TAT
• Claims Accuracy Rate
• Quality Audit Score
• Team Productivity
• Customer Satisfaction Score (CSAT)
• Grievance Resolution Efficiency
• Fraud Detection & Prevention Effectiveness
• Regulatory & Audit Compliance
• Cost and Claim Leakage Control