DM-Ops-Claims (Thane )

Job description

**Job Purpose** The role is responsible for settlement of all claims for assigned verticals & to either process or repudiate as per set guidelines and close within defined TAT. **Job Context & Major Challenges** **Job Context & Challenges** 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. Key Challenges for the role – Knowledge of Claims processes: Indemnity (Cashless, Reimbursement), Fixed Benefit Products Understanding of Claims systems (process flow & System fields) – Health, PA & Travel Experience in measurement of performance (TAT, accuracy in claims adjudication) Expectations management of the Claims team TAT & expectations management for specialized business handling. **Key Result Areas** **KRA (Accountabilities) (Max 1325 Characters)** **Supporting Actions (Max 1325 Characters)** KRA1 Processing & Monitoring of Indemnity and Fixed Benefit Claims 1. Monitor Claims transactions, authority limits, TATs - Appropriate & timely resolution of escalations - Monitor Claims Team Performance metrics KRA2 Address queries / complaints 1. Address queries from Customers, Intermediaries, Sales, other departments within defined TAT - Respond to Claims queries coming from the Company, Audit Training / BCP / Risk, Review, MIS / Compliance KRA3 Facilitate training: Self, Claims officers & non-medical resources 1. Acquire required technical qualification and training. - Update and provide guidance to the New Joinees about the Internal as well as external processes KRA4 Proactive Claims Calling Intelligence Proactive Claims Calling: Managing Claims Queries, assistance with customer during claims cycle. Maintaining a data of Claims Calling done in a pre-defined format. Building intelligence out of it which can be used for betterment of claims Experience.