Assistant/Deputy Manager - Claims

Role summary

This position is focused on coordinating with a claims service partner to ensure that travel and OPD claims are settled on time. The role also requires periodic medical and technical review of claims approved by the partner, along with maintenance of claims MIS and reporting.

Business and reporting structure

Business: Financial Service – HO

Unit: Aditya Birla Health Insurance Company Ltd

Location: Thane, Telangana, India

Function: Services Operations

Department: Claims

Employee designation: Assistant/Deputy Manager

Manager designation: Manager / Sr. Manager

JD updated on: 08.01.2024

Job purpose

The role exists to manage timely claim settlement for travel and OPD claims by working closely with the service provider team. It also includes ongoing medical and technical audits of approved claims and the upkeep of related MIS and reports.

Scope and scale

Business workforce: On roll 6000+, off-roll/part-time 4000+

Unit workforce: On roll 6000, off-roll/part-time 4000+

Function workforce: On roll 800, off-roll/part-time 279

Department workforce: On roll 69, off-roll/part-time 66

Job context and key challenges

The main challenge in this role is maintaining quality in the claims process and audit while ensuring turnaround time is met in line with the agreed SLA.

Key result areas

• Prepare and submit periodic as well as ad hoc claims reports accurately and on time.
• Resolve audit observations and close them through follow-up and corrective action.
• Complete monthly, quarterly, and annual data submissions in coordination with relevant stakeholders.
• Manage claim-related data and MIS with support from internal and external data teams.
• Monitor debit notes and checkpoints for payments from TPAs and OPD partners.
• Support MVP rollouts and process enhancements with OPD partner leadership and technology teams.

Supporting actions

• Use Excel shortcuts, formulas, and other tools or methods to speed up report preparation.
• Perform basic sanity checks before final submission of reports.
• Train partner claim processors on policy terms and conditions, time management, delegation, and related process points.
• Coordinate strongly with other departments and work with a proactive, solution-oriented approach.
• Review LDR reports, daily intimation reports, monthly TAT MIS, and OPD FWA savings data.
• Validate payment checkpoints such as DOA, date of discharge, policy period, admission dates, claim amount versus paid amount, and other critical fields.
• Work with partner teams to implement FWA triggers, automated ICD-10 coding, digitalized reports, API integrations, dashboards, and rule-engine alignment.
• Ensure partner systems can support required fields, query handling, utilization controls, portal access, and ABHI-format communications and reports.

Internal and external relationships

Internal: Coordinate with the MIS team on data requirements and the template used for partner payment processing.

External: Interact with service providers as needed to support claim decisions, reconsideration cases, claims beyond partner authority, and process or system improvements.

Organizational notes

The JD mentions that the organizational structure should show the level above and below the role, and that sign-off for the manager and job holder is required for the hard copy record.

Additional information

Job holder reports to: Manager

Direct reports: Not applicable

Document control: A signed hard copy of the JD is to be maintained in organizational records.

Important system and process requirements

• Claims processing should support automated FWA triggers and automated ICD-10 coded data.
• Health check-up utilization should be directed toward home collection rather than hospitals where applicable.
• FWA investigations must be completed at the agreed percentage on the partner side.
• The reimbursement adjudication rule engine should align with ABHI processes.
• Real-time client dashboards should be available for reviews.
• ABHI should have system access for claim approval.
• Communication letters, reports, and payment vouchers should be available in ABHI format.
• All fields needed for audits must be captured in the partner system, including mandatory debit-note fields.
• Deficiency-based query handling should be available.
• Medicos should process OPD claims.
• Data digitization, automated reporting, API integration, and utilization limits/sub-limits should be supported.
• Cashless portal access should work end to end.
• A daily claim outstanding report should be shared.
• Symptom-based linking should be available before consultation slot booking.

Terms and conditions / sign-off

The JD states that the manager’s name and the job holder’s name and signature are required on the hard copy, and that the signed document must be retained in the organizational records.