About the role

Job description

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.

Job Dimensions

Geographic Area Covered	Pan India
Stakeholders Internal	FIU team, sales team, product team, legal team, complaints team
External	Customer/ Policyholder, Vendor- Prorisk/ Medi Assist

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 stakeholder’s 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

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

Characteristics

	Essential
Qualification	Doctor
Experience	4-5 years of experience in Health claim processing

Manager – Claims

About the role

Job description