Manager - Health Claims

Job description

A Position Overview Position Title - Manager Department - Health Claims 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. B Organizational Relationships Reports to - AVP C Job Dimensions Geographic Area Covered - Pan India Stakeholders - Internal FIU team, sales team, product team, legal team, complaints team External Customer/ Policyholder, Vendor D 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 stakeholders 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 E 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 Behavioral Essential - • Analytical & Excel Skills • Communication skills • Teamwork Skills • Relationship Building skills • Decision making skills Desired - • Influencing skills • Supervising/Leadership skills F Incumbent Characteristics Essential Qualification - Doctor Experience - 8 - 10 years of experience in Health claim processing